Brief Communications

Migrainous vertigo presenting as episodicpositional vertigo

Michael von Brevern, MD; Andrea Radtke, MD; Andrew H. Clarke, PhD; and Thomas Lempert, MD

AbstractMigraine can cause vestibular symptoms including positional vertigo. Of 362 consecutive patients presentingwith positional vertigo, 10 with migrainous vertigo mimicking benign paroxysmal positional vertigo (BPPV) were identi-fied. The following factors help to distinguish migrainous positional vertigo from BPPV: short-duration symptomaticepisodes and frequent recurrences, manifestation early in life, migrainous symptoms during episodes with positionalvertigo, and atypical positional nystagmus.

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Migraine as a cause of recurrent vertigo1 is sup-ported by epidemiologic studies.2-4 Migrainous ver-tigo (MV) is a clinically heterogeneous disorder thatcan present with any combination of recurrent spon-taneous vertigo, positional vertigo, or head motionintolerance.4 Most patients do not fulfill criteria ofbasilar migraine and cannot be classified accordingto International Headache Society (IHS) criteria.Therefore, we recently proposed criteria to definedefinite and probable MV based on a history of mi-grainous symptoms that are temporally related tovertigo.4

Benign paroxysmal positional vertigo (BPPV) isthe most common cause for positional vertigo andcan be confirmed by positioning testing and observa-tion of typical nystagmus.5 Typically, BPPV mani-fests itself with symptomatic episodes lasting a fewweeks or months, which are interspersed by asymp-tomatic intervals of several months to yearsduration.

Patients with MV can also present with isolatedepisodic positional vertigo of short duration, mimick-ing BPPV (pseudo-BPPV). We conducted this retro-spective chart review to characterize the clinicalpresentation of these patients and to identify factorsthat may help to distinguish episodic positional MVfrom BPPV.

Methods. From January 1997 to December 2002, 362 outpa-tients were referred to our clinic with positional vertigo. We re-viewed charts to identify patients with MV who presented withshort-lasting attacks of isolated positional vertigo.

The diagnosis of definite MV was based on the criteria proposedby Neuhauser et al.4 The first criterion concerning vestibular symp-toms was modified to identify patients with pseudo-BPPV. Thisincludes episodic positional vertigo of 1-minute duration, mi-

graine according to the IHS criteria, at least one of the followingmigrainous symptoms during at least two episodes with recurrentpositional vertigo (migrainous headache, photophobia, phonopho-bia, visual or other auras), and other causes ruled out by appropri-ate investigations.

The criteria for probable MV presenting as pseudo-BPPV wereepisodic positional vertigo of 1-minute duration, at least one ofthe following (migraine according to the criteria of the IHS, mi-grainous symptoms during episodes with positional vertigo,migraine-specific precipitants of vertiginous episodes, response toantimigraine drugs), and other causes ruled out by appropriateinvestigations.

Case report. A 59-year-old man presented with a history ofpositional vertigo, provoked by turning over in bed, lying down, orbending over. He reported attacks of 1-minute duration thatrecurred during episodes lasting a few days. There had been threeepisodes within 2 years, each of them remitting without medicaltherapy. In addition, he had experienced an episode of presumedvestibular neuritis with rapid recovery of caloric function 5 yearspreviously. The neurologic and neuro-otologic examination includ-ing caloric testing was normal, and a provisional diagnosis ofBPPV was made. Four months later, the patient presented duringa symptomatic episode with positional vertigo that was initiallyaccompanied by severe bilateral throbbing headache starting inthe upper neck and radiating to the forehead. DixHallpike posi-tioning was negative, but rotation of the head to the right or to theleft in the supine position revealed persistent horizontal nystag-mus toward the lower ear (geotropic) with concomitant vertigo(figure). Further inquiry revealed a history of migraine withoutaura (severe, throbbing headaches with nausea lasting severalhours) and that previous episodes of positional vertigo were alsoaccompanied by such headaches. The symptoms subsided sponta-neously after 2 days.

Results. Five of 362 patients with positional vertigo ful-filled the criteria for definite MV and presented withpseudo-BPPV. Another five patients had probable MV withepisodic positional vertigo (table). Eight of these 10 pa-tients were female and 2 male. Age at manifestationranged from 13 to 60 years (median 49 years). In seven

From the Neurologische Klinik Charit (Drs. Von Brevern, Radtke, and Lempert), Campus Virchow, and Abteilung fr Hals-Nasen-Ohren-Heilkunde (Dr.Clarke), Klinikum Benjamin Franklin, Berlin, Germany.Received April 10, 2003. Accepted in final form September 17, 2003.Address correspondence and reprint requests to Dr. M. von Brevern, Neurologische Klinik Charit, Campus Virchow-Klinikum, Augustenburger Platz 1,13353 Berlin, Germany; e-mail: michael.von_brevern@charite.de

Copyright 2004 by AAN Enterprises, Inc. 469

patients, the duration of episodes never exceeded a fewhours or days. Only two patients reported episodes of aduration up to weeks. Four patients reported 20 epi-sodes. Two patients had onset of episodic positional vertigoin adolescence and reported 50 episodes. None of thepatients had auditory complaints or neurologic symptomsapart from vertigo during their episodes. Bedside examina-tion of ocular motor function was normal in the symptom-free interval in all patients. Four patients were examinedduring the symptomatic episode and showed positionalnystagmus atypical for BPPV, which on follow-up after 1 to4 weeks had disappeared. In two patients (Patients 1 and2), the initial diagnosis of BPPV had to be revised whenpresenting during the symptomatic episode. MRI of thebrain in three patients and caloric testing in six patientsyielded negative results.

Discussion. We identified a group of patients withMV presenting with episodic positional vertigo. Thisstudy was prompted by our clinical experience thatMV can mimic BPPV, leading to false diagnosis, par-ticularly when patients present during the symptom-free interval.

MV is still a widely neglected differential diagnosisof positional vertigo. Although a number of clinical re-

ports attribute vestibular symptoms to migraine, onlya few describe positional vertigo or dizziness in pa-tients with MV, with frequencies ranging from 17 to46%.2,6 Most of these patients had positional vertigo incombination with recurrent spontaneous vertigo, andonly 1% presented with positional vertigo as the solevestibular manifestation.6

Are there any factors that may help to differenti-ate pseudo-BPPV in MV from BPPV? When a patientwith migraine presents with vertigo that is repeat-edly accompanied by migrainous symptoms, MV ishighly probable.4 Frequently, however, vertigo is ac-companied only by subtle migrainous symptoms (i.e.,photophobia) that have to be specifically inquiredabout. Furthermore, the diagnosis of MV can be ob-scured by a temporal dissociation of vestibular andmigrainous symptoms.2,4,7

Our study suggests that case history and clinicalexamination may help discriminate episodic posi-tional MV from BPPV. Thus, the majority of ourpatients reported a duration of episodes of hours todays, whereas in BPPV, episodes typically last weeksto months without therapy.8 Seven of 10 patientsreported two or more symptomatic episodes per year,

Figure. Video-oculographic recording of persistent geotropic positional nystagmus in a patient with migrainous pseudo-benign paroxysmal positional vertigo (Patient 1). Note that there is also some right-beating nystagmus in the supine posi-tion. Recordings of horizontal (H), vertical (V), and torsional (T) eye movement components are shown. Torsional eyemovements are defined as clockwise (CW) or counterclockwise (CCW) from the patients point of view.

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contrasting with BPPV, where 15% of patients expe-rience recurrence within 1 year.9 Two patients withmany episodes reported onset of pseudo-BPPV in ad-olescence, whereas BPPV rarely occurs in youngage.5 Finally, as described above, analysis of posi-tional nystagmus usually permits differentiation ofpositional MV from BPPV. Positional nystagmusatypical for BPPV has been reported in a previouscase series of patients with MV.6 Notably, patientsmay report short attacks of positional vertigo mim-icking BPPV, even if witnessed attacks involve per-sistent positional vertigo and nystagmus (see thecase report). This can be explained by the reaction ofmost patients to leave the provoking position as soonas possible.

When a patient presents acutely with a first epi-sode of positional MV, a cerebellar or brainstem le-

sion should be considered, in which case MRI shouldbe performed. Other causes of positional vertigo, un-related to migraine, include perilymph fistula andneurovascular compression of the eighth cranialnerve. Vertigo in perilymph fistula is usually precip-itated by transient pressure changes in the inner ear(e.g., caused by sneezing, coughing, loud sounds),whereas attacks in neurovascular compression of theeighth cranial nerve may occur both spontaneouslyand after positional change.

The pathophysiology of MV is still a matter ofspeculation. Several anatomic and functional inter-faces between the vestibular system and mechanismsinvolved in migraine have been identified, includingrelease of neuropeptides, vasoconstriction, spreadingdepression involving cortical or possibly brainstemstructures processing vestibular signals, and a genetic

Table Clinical characteristics of patients with definite and probable migrainous vertigo presenting with pseudo-BPPV

Patient no.Sex/

age, y

Age atmanifestation,

y

Durationof

episodesNo. of

episodes

Migrainesymptoms during

episodes Nystagmus during episodeFeatures atypical for

BPPV

Definite migrainousvertigo

1 M/59 57 24 d 4 Headache (/) Persistent geotropichorizontal nystagmus inboth lateral supinepositions

Nystagmus,migrainoussymptoms, durationof episodes

2 M/52 42 Daysweeks

20 Headache (/) Persistent apogeotropichorizontal nystagmus inleft lateral supineposition

Nystagmus,migrainoussymptoms, no. ofepisodes

3 F/42 40 12 d 3 Headache (/) Transient purely torsionalnystagmus in both lateralsupine positions

Nystagmus,migrainoussymptoms, durationof episodes

4 F/47 46 13 d 5 Headache (),photo (/)

NA Migrainous symptoms,duration of episodes

5 F/67 52 12 h 50 Headache (/),photo/phono ()

NA Migrainous symptoms,no. of episodes,duration of episodes

Probable migrainousvertigo

6 F/37 13 110 d 50 None NA Age at manifestation,no. of episodes

7 F/57 18 6 h 100 None NA Age at manifestation,no. of episodes,duration of episodes

8 F/62 60 12 d 5 None NA Duration of episodes

9 F/66 56 Hoursweeks

5 None Transient downbeatnystagmus in rightlateral supine position

Nystagmus

10 F/61 55 12 h 3 None NA Duration of episodes

Eight patients had migraine without aura, and one patient had migraine with aura. Patient 7 presented with migrainous disorder (intense bilat-eral throbbing headache of several hours duration, association with menstruation, first-degree relatives with migraine, but lack of photo/phono-phobia or nausea.

BPPV benign paroxysmal positional vertigo; (/) vertigo occurring both with and without migrainous symptom; () vertigo occurringregularly with migrainous symptom.

February (1 of 2) 2004 NEUROLOGY 62 471

defect of ion channels.1,7 Our observation of positionalnystagmus atypical for BPPV in the acute phase sug-gests that positional MV results from dysfunction ofvestibular structures in the brainstem or vestibulocer-ebellum, presumably inhibitory fibers from the nodulusand uvula to the vestibular nuclei.10

References1. Baloh RW. Neuro-otology of migraine. Headache 1997;37:615621.2. Kayan A, Hood JD. Neuro-otological manifestations of migraine. Brain

1984;107:11231142.3. Kuritzky A, Ziegler DK, Hassanein R. Vertigo, motion sickness and

migraine. Headache 1981;21:227231.

4. Neuhauser H, Leopold M, von Brevern M, Arnold G, Lempert T. Theinterrelations of migraine, vertigo, and migrainous vertigo. Neurology2001;56:436441.

5. Baloh RW, Honrubia V, Jacobson K. Benign positional vertigo: clinicaland oculographic features in 240 cases. Neurology 1987;37:371378.

6. Dieterich M, Brandt T. Episodic vertigo related to migraine (90 cases:vestibular migraine?) J Neurol 1999;246:883892.

7. Cutrer FM, Baloh RW. Migraine-associated dizziness. Headache 1992;32:300304.

8. Brandt T, Daroff RB. Physical therapy for benign paroxysmal positionalvertigo. Arch Otolaryngol 1980;106:484485.

9. Nunez RA, Cass SP, Furman JM. Short- and long-term outcomes ofcanalith repositioning for benign paroxysmal positional vertigo. Otolar-yngol Head Neck Surg 2000;122:647652.

10. Bttner U, Helmchen C, Brandt T. Diagnostic criteria for central ver-sus peripheral positioning nystagmus and vertigo: a review. Acta Oto-laryngol 1999;119:15.

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