|Year : 2019 | Volume
| Issue : 1 | Page : 19-22
Prevalence of vestibular migraine in Dubai
Teja Deepak Dessai, Samer Sakka Amini, Faisal Asad, Helen Kutty
ENT Department, Saudi German Hospital, Dubai, UAE
|Date of Web Publication||27-Feb-2019|
Teja Deepak Dessai
Vaishnovi Apartments, 301 Apartment, 3rd Floor, Near New Chitra Talkies, Mangalore, Karnataka
Source of Support: None, Conflict of Interest: None
Introduction: A vast number of adult persons suffering from vertigo associated with migraine are reported on a daily clinical practice. However, clinical identification of VM still remains hindered in Dubai due to dearth of agreement in diagnostic criteria. Aim: The aim of this study is to determine the prevalence of VM in the general population of Dubai. Methods: A total of 218 adult persons who visited outpatient otolaryngology and rhinology clinic in a given year 2017 with a complaint of vertigo were retrospectively studied and accounted in research. Further, labelling of each person was done based on the presented symptoms. Results and Discussion: To calculate the prevalence of VM, total number of each diagnosis was counted and was further subjected to a formula to calculate prevalence. Out of the 218 persons considered in the study, 30 were diagnosed with migraine (2 persons with migraine alone and 28 persons with VM). This accounts to a prevalence of 0.9% migraine alone and 12.8% VM in a clinical setting for 1 year. Conclusion: The high prevalence of VM in a clinical setup for 1 year hints toward the need for careful diagnosis of a person.
Keywords: Dubai, prevalence, vestibular migraine
|How to cite this article:|
Dessai TD, Amini SS, Asad F, Kutty H. Prevalence of vestibular migraine in Dubai. Hamdan Med J 2019;12:19-22
| Introduction|| |
Vestibular migraine (VM) is a form of recurrent vertigo as a symptom of migraine. Adults suffering from migraine between 18 and 79 years of age show a total of 7% lifetime prevalence of vertigo, 4.9% prevalence for 1 year and 1.4% incidence in 1 year. Acknowledgment of an association between migraine and vertigo was published by an English physician Edward living almost 150 years back. He noted 6 out of 60 patients with migraine had spontaneous attacks of vertigo. About 10% of individuals suffer from vertigo-associated migraine. However, the interrelations of migraine and vertigo are more intricate. In general population, the existence of common conditions such as vertigo and migraine may be by chance alone. Moreover, numerous vertigo syndromes have been quoted to be epidemiologically linked with migraine: benign paroxysmal positional vertigo, Meniere's disease, motion sickness, cerebellar disorders and several psychiatric syndromes which may present with dizziness. Approximately 50% of migraine patients are left mismanaged or undiagnosed. Many are self-treated or are inappropriately treated for sinus or other non-migrainous types of headache.
The prevalence of migraine has been explored by population-based studies in several countries on the basis of the International Classification of Headache Disorders. Dizziness alone being the most common complaint in medical field, it counts about 20%–30% of the general population.,, Industrialised countries show a lifetime prevalence ranging from 13%, to 16%., the prevalence of migraine in a given 1 year period conferring to a meta-analysis encompassing several studies from around the world has been estimated at 11%.
In addition, adults between 18 and 79 years of age showed a total of 7% lifetime prevalence of vertigo, 4.9% prevalence for 1 year and 1.4% incidence in 1 year. Fascinatingly, two to three times higher incidence is reported in women than men. Male-to-female prevalence ratio in 1 year showed a marked female preponderance of 1:2.7 among persons with vertigo. Moreover, recurrence of vertigo was estimated to 88% which, in turn, exhibits considerable impact on individual himself and social life, causing about 40% interruption of daily activities, 41% sick leave and 19% avoidance of leaving the house. An augmented comorbidity of migraine and vertigo has been identified in various persons. Vertigo is commonly reported in patients with migraine than in headache-free controls for almost two to three times, and in patients with tension-type headaches. Vice versa, elevated prevalence of migraine has been shown among persons with unclassified or idiopathic vertigo.,, Similarly, 1.6 times higher migraine prevalence was found in 200 persons from a dizziness clinic in comparison to orthopaedic controls. Lifetime prevalence of migraine (16%) and vertigo (7%) leads to 1.1% comorbidity of the two conditions in general population. A recent study showed that migraine was more likely to be associated with vertigo and vertigo with accompanying headache than non-migraineurs.
The prevalence of VM in a dizziness clinic of Egypt is reported to be 22% with vertigo either isolated or combined with the sense of imbalance accounting to over 60%. In addition, most common aural symptom quoted was phonophobia, followed by the sense of bilateral ear fullness and tinnitus. Positional nystagmus was also frequently recorded in 60% of the persons. Similarly, a study quotes a prevalence of 8.1% VM in Riyadh, Saudi Arabia. However, clinical identification of VM still remains hindered in Dubai and Middle East due to dearth of agreement in diagnostic criteria. The aim of this study was to determine the prevalence of VM in the general population of Dubai.
| Methods|| |
A prospective study was carried out from January 2017 to December 2017. A total of 218 adult persons who visited outpatient otorhinolaryngology clinic with the complaint of vertigo were included in the study. A detailed case history was noted and counted for the diagnosis of the person with respective terminology. The diagnosis was carried out based on the traditional approach for each case (case history and subjective and objective test results). However, for the diagnosis of VM, the following diagnostic criteria in [Table 1] were considered., A full neuro-otologic evaluation was completed for each person diagnosed with VM by specialised audiologists. Case history and primary complaint of dizziness were thoroughly analysed, and intake of medications (either for dizziness or migraine) was also registered. Further, persons diagnosed with migraine on clinical evaluation were asked to undergo brain magnetic resonance imaging (MRI) to rule out any central anatomical pathology and only persons with normal brain MRI were included in the study. If the condition did not suit in peripheral causes of vertigo and/or a central cause was suspected; a neurology consultation was requested.
An informed consent was taken from the patients before enrolling in the research study, and the diagnosed persons were further tabled and analysed.
| Results and Discussion|| |
Dearth of awareness about migraine as an explicit cause for headache is very prevalent in this given community. In fact, in spite of the clear diagnostic criteria of migraine from literature and investigations, almost above 70% of the persons in the study were not diagnosed. Besides, about 80% of the persons came in with a long-standing history of migraine. However, no association was made between their headache and dizziness either by their referring physicians or by themselves. The investigative standards of the consensus article of the International Bárány Society for Neuro-Otology and the International Headache Society (2013) combine the characteristic signs and symptoms of migraine with the vestibular symptoms lasting for 5 min to 72 h. Although VM accounts for 7% of patients seen in dizziness clinics, it still remains underdiagnosed. In the current study, a total of 218 persons were recruited and were further considered for statistical analysis in calculation of prevalence of VM.
To calculate the prevalence of VM, total number of each diagnosis was counted and was further subjected to below formula to calculate prevalence.
VM is a common disorder presented in the vertigo clinics. Therefore, a detailed assessment consisting of history and other necessary tests (subjective and objective) is very essential to confirm the diagnosis or to prevent underdiagnoses. From [Table 2], we can comprehend that out of the 218 persons considered in the study, 30 were diagnosed with migraine (2 persons with migraine alone and 28 persons with migraine associated with vertigo). This accounts to a prevalence of 0.9% migraine alone and 12.8% VM in a clinical setting for 1 year. The total prevalence was 13.76% in the clinical setup for 1 year. In addition, the episodes of migraine with vertigo lasted between 4 and 24 h. The investigators of this study also put forth the manifestations of migraine-associated vertigo being quite varied. This included episodic true vertigo, constant imbalance, positional vertigo, disequilibrium and/or light-headedness. Symptoms occurred before the onset of headache, during a headache or during a headache-free interval. These findings are in concordance with the study carried out in Egypt. The co-occurrence of vertigo and migraine was not uniform in all the patients. Persons complained of migraine followed by vertigo and vice versa. This pattern was noted to be varied in each patient at every single episode. Moreover, high levels of anxiety were also explained in the case history by the persons suffering from VM.
|Table 2: Total number of persons diagnosed in a clinic for 1 year and prevalence of each vestibular pathology|
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The findings of the study are in concordance with the literature. VM has been estimated to affect 15%–20% of adult men and 23%–29% of adult women. The total prevalence of VM is quoted to be 25% in migraine patients. This suggests that migraine can commonly cause episodic vertigo and needs immediate attention to prevent persons from further sufferance. Since majority of the counted persons with migraine showed high proportion of vestibular aura, it seems likely that a thorough differential diagnosis should be done to rule out the presence of Meniere's disease with quoted prevalence of 22% or benign paroxysmal positional vertigo with prevalence of 19.4%.
Literature concludes that innervations of trigeminal nerve in labyrinth vessels and vasoactive neuropeptide localisation in the perivascular afferent terminals of these trigeminal fibres support the participation of the trigeminovascular system. Therefore, the neurogenic inflammation generated by activation of the trigeminal-vestibulocochlear reflex, with the following inner ear plasma protein extravasation and release of inflammatory mediators, may contribute to a sustained activation and sensitisation of the trigeminal primary afferent neurons explaining the symptoms of VM. The reciprocal influences between brainstem vestibular nuclei and the structures that modulate trigeminal nociceptive inputs (ventrolateral periaqueductal grey, rostral ventromedial medulla, locus coeruleus and nucleus raphe magnus) are critical to comprehend the pathophysiology of VM. In addition, although cortical spreading depression can affect cortical areas involved in processing vestibular information, functional neuroimaging techniques propose a dysmodulation in the multimodal sensory integration and processing of vestibular and nociceptive information, resulting from a vestibulo-thalamo-cortical dysfunction, as the major pathogenic mechanism underlying VM. The eminent prevalence of VM suggests multiple functional variants concluding a genetic susceptibility leading to a dysregulation of excitatory–inhibitory balance in brain structures involved in the processing of sensory information, pain and vestibular inputs. The interactions among several functional and structural neural networks could explain the pathogenic mechanisms of VM.
Only limited randomised controlled studies have been carried out on the specific treatment of VM: during the attack or as prophylaxis. Since none of the accessible studies to date are satisfactory, most therapeutic recommendations for the prophylactic treatment of VM are nowadays based on the therapy guidelines for migraine with and without aura.
| Conclusion|| |
The study aimed and revealed high prevalence of VM in Dubai. The high prevalence of VM in a clinical setup for 1 year hints toward the need for careful diagnosis of a person. However, the sample size considered in the study accounted for only 1 year, and hence, future need for bigger studies is essential.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2]