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Balance/Vestibular

Balance/Vestibular

Ask the Expert: Vestibular Migraine

Ask the Expert: Vestibular Migraine

Vestibular Migraine: Kristen Steenerson, MD

1. What are the diagnostic criteria for vestibular migraine?

The criteria for vestibular migraine were developed jointly by the Barany Society and the International Headache Society in 2012. As vestibular migraine was still a newly accepted diagnosis at that time, strict diagnostic criteria were developed to establish universal research standards. As a result, many patients who have vestibular migraine may not fit into the classic criteria established over seven years ago. As the current criteria stand, patients are required to have at least five moderate to severe attacks of vertigo (defined as any hallucination of movement, not just spinning) lasting 5 minutes up to 72 hours at a time. With these attacks, migrainous features such as headache, photophobia, phonophobia or visual aura must be present half of the time. Finally, a previous or current history of more classically understood migraine helps to clinch the diagnosis.

2. What are common clinical signs and symptoms for patients with suspected vestibular migraine?

​Patients with vestibular migraine typically have attacks of spinning, tilting, rocking, sway and imbalance. These are usually spontaneous, but can be linked to stress, poor sleep, dehydration, skipping exercise and meals. In between attacks, it is very typical for patients to have hypersensitivity to motion, sound, light, smells and medications. When evaluated by physicians, many of these patients are considered normal. However, with a keen eye, physicians will notice vestibular migraine patients have increased head motion sensitivity, visual motion sensitivity, and postural imbalance with exaggerated sway on occasion compared to patients without VM.

3. Are there specific vestibular tests that you find helpful for diagnosing vestibular migraine?

Unfortunately, there are still no gold standard diagnostic tests for vestibular migraine. Some interesting studies have been published highlighting some patterns in vestibular testing that may be helpful, but these are still in nascent stages and of uncertain generalizability. I find it still very useful to order the full battery of audiovestibular tests to make sure other vestibular disorders have been considered, especially Meniere's Disease, due to the considerable overlap in symptoms. 

4. What management strategies are most helpful?

​There are two main approaches to management: prevention and rescue.

  1. Prevention focuses on reducing the total number of attacks and frequency of attacks that occur. A good prevention plan will reduce severity and frequency by 50%; it is rare that patients will see complete resolution of attacks. Prevention plans include lifestyle changes, medications and physical therapy. Lifestyle changes can be very effective in most patients and may be all that is needed. For lifestyle, we use the mnemonic SEEDS: Sleep, Exercise, Eating, Dehydration and Stress management. Regular sleep, exercise, drinking water (avoiding dehydrating drinks like caffeine/alcohol) and eating schedules can be helpful in reducing triggers for migraine attacks. Stress management is also a key lifestyle modification that comes in different forms for different people: meditation, mindfulness, talk therapy, exercise, work modifications and sometimes medications. Medications used for prevention are borrowed from the migraine headache literature. These can range from over the counter nutraceuticals such as magnesium and riboflavin to prescription medications such as antihypertensives, antidepressants, and anti-epileptic medications. Vestibular physical therapy can help desensitize the brain to head/body motion and visual motion to help reduce triggering of attacks.
  2. Rescue focuses on reducing the duration and severity of an attack when it occurs. Medications typically used include anti-nausea, anti-inflammatory, anti-migraine, anti-histamine and anxiolytic properties that have dual purpose as vestibular suppressants. These medications must be used with caution as they are not intended to be used long term and can have longterm side effects. They are very safe if used a few times a month. 

5. Are medications available for vestibular migraine?

In the United States, we commonly use already-established medications used in migraine headaches. These can range from over the counter nutraceuticals such as magnesium and riboflavin to prescription medications such as antihypertensives, antidepressants, and anti-epileptic medications. These are generally effective, but can sometimes require trialling a few different ones before a patient finds relief. There are no randomized controlled trials that support one medication over another in vestibular migraine in the United States. Europe and other countries have trials supporting the medications flunarizine and cinnarizine, but these are not available in the US. 

6. Is vestibular migraine treated differently than other migraines?

​Yes and no. In many ways the treatments are similar. Due to vestibular migraine's unique motion sensitivity and balance difficulties, there is a singular role for vestibular therapy that is not commonly seen in more typical migraine. As more studies are completed, there may be evidence of unique pathophysiologic processes for vestibular migraine compared to migraine headaches, which may implicate emphasis on different types of medications, but this is yet to be definitively established. 

7. Do you recommend vestibular rehabilitation?

​Yes. In the hands of an experienced vestibular therapist, I find that many vestibular migraineurs improve in terms of balance and motion sensitivities. There are severe cases where even the most gentle of ocular motor or balance exercises exceed the threshold of what a patient can tolerate. For those individuals, we will usually attempt lifestyle and medication interventions first before trying vestibular therapy. 

8. What would you want the general public to know about vestibular migraine?

  1. Vestibular migraine is incredibly common. Up to 3% of the general public has vestibular migraine.
  2. It is important to recognize that headaches do not need to be a prominent feature in order to be diagnosed with vestibular migraine.
  3. It is likely an inherited disorder that can become active with certain environmental factors such as stress, hormone fluctuations (e.g. menopause/perimenopause) and irregular sleep/eating/exercise/drinking schedules.

9. What is your overall key take home message for providers working with patients with suspected vestibular migraine?

Vestibular migraine, like other forms of migraine, is an episodic, neurologic, hypersensitivity disorder. Central nervous system and peripheral nervous system pathways are preferentially affected, resulting in vestibular attacks of variegating types of motion and motion sensitivity. As these pathways can sometimes activate independent from pain pathways, vestibular migraineurs can have isolated vestibular events without headache, thus absence of headache should not dissuade the diagnosis. Lifestyle changes are paramount, medications can be helpful, and physical therapy can be useful for treatment in many of afflicted patients.

10. Are there any other specialties you’ve found helpful to include in a vestibular migraine patient’s plan of care?

Due to known connections between the vestibular circuits and the emotional circuits of the central nervous system, most patients experience an increase in anxiety and/or depression related to their vestibular migraine. Attacks are unpredictable and frightening and if suboptimally controlled can trigger maladaptive coping such as panic attacks, hypervigilance and catastrophization. Due to the connection to mood changes, psychological support such as talk therapy and meditation can be beneficial for coping with this distressing disorder. 

Ask the Expert: Vestibular Disorders

Ask the Expert: Vestibular Disorders

Vestibular Disorders: Habib Rizk, MD

1. Dizziness is a common symptom reported by many patients. As an otologist, what about patient-reported dizziness is most concerning to you? What disorders do you most commonly see in the clinic?

Any patient presenting with new neurologic symptoms associated with their dizziness requires a thorough evaluation to look out for central causes. These symptoms could be new onset headaches, slurred speech, paresthesia, weakness in lower or upper limbs. Also, patients with loss of consciousness need to be evaluated to rule out a hemodynamic cause or an arrhythmia. Finally, patients with dizziness associated with audiologic symptoms orients more toward a peripheral inner ear disorder.

In our multidisciplinary dizziness clinic, Meniere’s disease and vestibular migraine and BPPV account for about 50% of our new patients

2. Are there differences based on age? Do kids have the same trouble with dizziness as adults?

In children, migraine equivalents are the most frequent causes of dizziness, as well as post concussive dizziness. While vestibular migraine is prevalent in adults, benign paroxysmal positional vertigo is still the most frequent cause of vertigo in adults. Dizziness is a general term and can encompass vertigo, lightheadedness, imbalance.

3. Many patients have been diagnosed with Meniere’s disease. What is Meniere’s disease? What management is available Meniere’s disease?

Meniere’s disease is a pathology that affects the pressure control of the inner ear fluids resulting in fluctuating symptoms of ear pain, tinnitus and vertigo lasting between 20 minutes and 12 hours. There is a high association with migraines in a large subset of patients. Treatment ranges from low salt diet and diuretics to intratympanic steroids, intratympanic gentamicin injections and surgeries: to preserve hearing such as endolymphatic sac decompression or vestibular neurectomy or that are not hearing preserving such as labyrinthectomy.

4. If a patient experiences a sudden onset of spinning vertigo, should the patient immediately go to the emergency department or is there an alternative pathway to care that you would recommend?

A brief episode of vertigo (room moving or subject feeling that they are moving) lasting less than a minute and triggered by a change in head position, typically would not require a specialized evaluation and is usually a benign paroxysmal positional vertigo. However, as a precaution it is important to be evaluated to see if there is any reason to suspect a stroke. Rarely, posterior fossa strokes will manifest only as vertigo without associated symptoms

5. I’ve been diagnosed with positional vertigo. Is it possible for this to return? What can I do to reduce my risk?

Yes. BPPV is known to recur and that incidence is often quoted to be 10% per year meaning a subject with positional vertigo has a 10% chance of having another “attack” in the same year. Any disorder affecting the inner ear such as meniere’s disease as well as vestibular migraine seems to increase the chances of this happening. Also, low levels of vitamin D have been considered a risk factor in bppv and supplementing for vitamin D deficiency is a low cost low risk intervention that may help (jury is still out on this one)

6. Are there medications that can help with my dizziness?  Alternatively, are there any medications that could potentially worsen a patient’s symptoms or recovery?  What about other treatment options?

During an acute attack of vertigo, meclizine, valium, promethazine may be used. If patient is vomiting, suppositories may be necessary. However, taking them long term is going to affect the brain’s ability to compensate and thus it is not advisable to stay on those medications indefinitely. Depending on the cause of the dizziness, a short course of steroids may be indicated as well as preventive therapy for migraines or for meniere’s disease

7. Imbalance is a significant concern for adults as we age. Why is this the case? Do you have guidance on when to seek out balance therapy resources?

As our population is getting older (a child born today is expected to live to be 130 years old), our sensory systems are aging as well. The same way vision is affected and hearing is affected, balance is also affected. Loss of the function of balance of the ears (vestibular function), loss of proprioception (back pain, hip pain, joint pain , reduced muscle mass) and reduced visual acuity increase dramatically the risk of falls. This in itself cause significant injuries and increase mortality in the elderly. If there is any concern for falls, near falls, hesitant gait or dizziness, a patient needs to be evaluated by a vestibular specialist and started on a vestibular rehab program that will significantly reduce that risk

8. What other specialists might be involved in the diagnosis and management of a patient with a suspected vestibular disorder?

Audiologists to perform an array of vestibular testing that will give us an idea of how the vestibular system is functioning. Vestibular therapists that are primordial in setting up a physical therapy/rehabilitation plan

9. What would you want the general public to know about vestibular disorders?

It is an invisible problem. It can have a significant toll on people from the functional, emotional and even cognitive standpoint. If you have a relative or a friend with a diagnosis of vestibular dysfunction, accepting an injury you cannot see will go a long way helping those patients go on the path to recovery. It is not “in their head”.

10. What is your overall key take home message for providers working with patients with vestibular disorders?

Do not underestimate the pervasive impact of a vestibular dysfunction on your patient’s overall health and functioning. New data even shows potential links with progression to dementia. This goes to say how important is our vestibular function in many dimensions of our lives. A thorough assessment to rule out severe etiologies (tumors, strokes) and to make a good functional assessment, will allow you to establish a multidisciplinary plan of care that should impact their quality of life tremendously.

 

Habib Rizk, MD, MSc, grew up in Beirut, Lebanon, and is a graduate of the French Faculty of Medicine-Saint Joseph University in Beirut Lebanon. Dr. Rizk completed an Otolaryngology – Head and Neck Surgery (Ear, Nose and Throat, ENT) Residency at Hôtel-Dieu de France Hospital in Beirut with additional fellowship training in Otologic Medicine and Surgery Fellowship with Dr. Michael Teixido as well as in Neurotology at the Medical University of South Carolina (MUSC). He then joined the MUSC ENT Department as the director of the Vestibular Program, and established the only multidisciplinary program in the state of South Carolina to evaluate and manage patients with various causes of dizziness. He is on the board of directors of the American Balance Society, a member of the Equilibrium Committee of the American Academy of Otolaryngology – Head & Neck Surgery as well as a representative of the Academy in a joint task force with the American Academy of Neurology to investigate quality improvement measures in neurotology. 

Dr. Rizk is involved in hearing-related and dizziness-related research and has over 25 articles published.  He also authored several book chapters and published a book about anatomy of the ear geared toward teaching residents and medical students the complex anatomy of the ear and temporal bone. His interests pertain to all areas of otology and neurotology with a specific focus on medical and surgical management of vestibular disorders.

Balance Awareness Week

Balance Awareness Week

The Academy is proud to help support Balance Awareness Week—September 15–21, 2019.

Balance Awareness Week, an observance designated by the Vestibular Disorders Association (VeDA), aims to increase awareness about vestibular disorders and support patients in their journey back to balance. While many balance disorders are incurable, faster and more accurate diagnosis, along with effective coping strategies can greatly improve quality of life.

Audiologists play a key role in helping to diagnose and manage vestibular and balance disorders in adults and children.

The Academy has collaborated with VeDA to develop resources on hearing loss and balance and to help educate other health-care providers, the media, and consumers about the audiologist’s role in balance care.

We partnered with VeDA to create this unique poster for Balance Awareness Week, featuring an infographic for Dizziness and Psychiatric Conditions.

Download Your FREE Poster and Support Balance Awareness!

Social Media Graphics and Ads

Academy Supports Balance Awareness Week

Download a skyscraper ad or graphics to share on Facebook, Instagram, and Twitter.  

Infographics

10 Questions for the Experts

VeDA Resources and Information

 

JAAA Editorial: The American Academy of Audiology Honors Committee: A Mechanism to Acknowledge Those in Audiology Who Have Gone Above and Beyond in Their Contribution to the Profession

Vol. 30, No. 7 (July/August 2019)
Gary P. Jacobson, Ph.D.
Editor-in-Chief, Journal of the American Academy of Audiology

The American Academy of Audiology Honors Committee: A Mechanism to Acknowledge Those in Audiology Who Have Gone Above and Beyond in Their Contribution to the Profession


Access JAAA online

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JAAA Latest Fast Track Articles—July 5, 2019

As the JAAA editors along with our editorial team, we are proud to announce new Fast Track content for JAAA, as of July 5, 2019. We are working diligently to publish ahead of print. We strive for a two-month turnaround on articles from acceptance to digital publication. Plan to see more of these announcements about content updates each month.

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CSI: Audiology Image

CSI AUDIOLOGY | Considering Birth History When It Comes to High-Frequency Hearing

Case History

The 26-year-old mother was healthy throughout the term of the pregnancy and went into labor at 40-weeks' gestation. The pregnancy was complicated just prior to delivery with a possible abruption. There was significant bradycardia with the heart rate of the patient down to 40 beats per minute prior to delivery. This required a stat cesarean section.

Topic(s): Hearing Loss, High Frequency, Balance/Vestibular, Patient care

Coding and Reimbursement Image

CODING AND REIMBURSEMENT | Advanced Beneficiary Notice of Noncoverage Use: Mandatory or Voluntary?

Understanding the correct use of the Advance Beneficiary Notice of Noncoverage (ABN) Form CMS-R-131 is important to ensure billing compliance for traditional Medicare (Part B). Audiologists may face challenges determining when Medicare covers a service and when an ABN is required. Federal law requires that providers, including audiologists, must notify a Medicare beneficiary in advance when a service that Medicare typically covers is likely to be denied and/or when the item or service is not considered by Medicare to be medically reasonable and necessary. The ABN meets this requirement.

Topic(s): Medicare, Coding, Reimbursement, Centers for Medicare and Medicaid Services (CMS), Balance/Vestibular

CSI: Audiology Image

CSI AUDIOLOGY | When Is Ménière’s Disease Not Ménière’s Disease?

Dizziness is a common complaint, with approximately 35 percent of adults reporting dizziness, with the prevalence increasing dramatically with age (Agrawal, 2009). As the profession of audiology has evolved, so has our understanding of the various disorders that cause imbalance and dizziness. This article will walk you through the case of Sunny Susan (patient’s name changed to protect identity), a woman who I first saw as a balance patient after she had spent over 22 years struggling with recurrent dizziness and progressive hearing loss. 

Topic(s): Dizziness, Balance/Vestibular, Meniere’s Disease (MD), conductive-mixed hearing loss, Hearing Loss, Tinnitus, Patient care

Author(s): 

Publication Issue: Audiology Today March/April 2018

Cheetahs Always Prosper, Thanks to Their Remarkable Vestibular System

Cheetahs hold the record for being the fastest land animal and are a top predator in their habitat. Watching a cheetah on a run-down is awe-inspiring, and with new high-speed cameras capturing every second, even more so. 

They can turn on a dime all while keeping their eyes focused on their prey and not miss a beat. What makes them so good? Turns out, in comparison to other felines, cheetahs have significantly larger vestibular structures, with a greater volume of the inner ear devoted to the vestibular structures.

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How We Make Decisions

The world is full of difficult decisions and our orientation in space may actually affect our ability to make them. Additionally, trying to make critical decisions in zero gravity may be even more challenging. 

A recent article highlights ongoing research regarding decision-making abilities while subjects experience altered gravitation situations. The information gained from these studies is important as longer duration space exploration occurs and the necessity to make the right decision in high stakes situations is critical to astronauts’ survival.

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