Migrainous vertigo

Prevalence and impact on quality of life

H.K. Neuhauser, MD, MPH; A. Radtke, MD; M. von Brevern, MD;
M. Feldmann; F. Lezius; T. Ziese, MD; and T. Lempert, MD
AbstractObjective: To investigate the epidemiology of migrainous vertigo (MV) in the general population by assessing
prevalence, clinical features, comorbid conditions, quality of life, and health care utilization. Methods: We screened a
representative sample of the adult population in Germany (n 4,869) for moderate or severe dizziness/vertigo and
followed up with validated neurotologic telephone interviews (n 1,003). Diagnostic criteria for MV were as follows: 1)
recurrent vestibular vertigo; 2) migraine according to the International Headache Society; 3) migrainous symptoms during
at least two vertiginous attacks (migrainous headache, photophobia, phonophobia, or aura symptoms); and 4) vertigo not
attributed to another disorder. In a concurrent validation study (n 61) the interviews had a sensitivity of 84% and a
specificity of 94% for vestibular vertigo and 81% and 100% for migraine. Results: The lifetime prevalence of MV was 0.98%
(95% CI 0.70 to 1.37), the 12-month prevalence 0.89% (95% CI 0.62 to 1.27). Spontaneous rotational vertigo was reported
by 67% of participants with MV while 24% had positional vertigo. Twenty-four percent always experienced headaches with
their vertigo. Logistic regression analysis comparing participants with MV with dizziness-free migraineurs showed an
independent association with coronary heart disease but not with sex, age, migrainous aura, education, stroke, hyperten-
sion, hyperlipidemia, body mass index, or depression. Age-adjusted health-related quality of life scores (SF-8 Health
Survey) were consistently lower in participants with MV compared to dizziness-free controls. Two thirds of participants
with MV had consulted a doctor but only 20% of these were diagnosed with MV. Conclusions: Migrainous vertigo is
relatively common but underdiagnosed in the general population and has considerable personal and healthcare impact.
NEUROLOGY 2006;67:10281033
Migrainous vertigo (MV) is a frequent cause of recur-
rent vertigo in patients presenting to specialized diz-
ziness clinics
1,2
and is also frequent in headache
clinic patients.
2
In the general population, lifetime
prevalences are estimated at 7% for vertigo
3
and 16%
for migraine.
4
The frequency of MV, i.e., of vertigo
causally related to migraine, however, is not known
at the population level. This recently recognized syn-
drome has thus far been investigated in specialized
care settings.
2,5-7
In this study, we sought to estimate the popula-
tion prevalence of MV in a nationally representative
sample of the general population in Germany
through validated neurotologic interviews applying
explicit diagnostic criteria. We further aimed to de-
scribe the clinical characteristics of MV, associated
sociodemographic characteristics, comorbid condi-
tions, health-related quality of life, and health care
utilization in an unselected general population
sample.
Methods. The neurotologic survey is a cross-sectional study
which investigated the epidemiology of dizziness and vertigo in
the general population with neurotologic interviews.
3
In brief, the
sampling design had two stages. First, a representative sample of
the adult general population in Germany consisting of 4,869 par-
ticipants of the German National Telephone Health Interview
Survey (GNT-HIS) 2003 aged 18 years were invited to partici-
pate in a further interview and were screened for moderate or
severe dizziness or vertigo in their past life. Out of 1,157 eligible
participants with dizziness and vertigo, 1,003 completed a de-
tailed neurotologic interview by telephone. The response rates
were 52% for the GNT-HIS 2003 and 87% for the neurotologic
survey.
We developed the neurotologic interview in a specialized dizzi-
ness clinic with the aim to differentiate vestibular vertigo from
non-vestibular dizziness and to identify four specific syndromes
according to explicit diagnostic criteria: MV, benign paroxysmal
positional vertigo (BPPV), Menie`res disease, and orthostatic diz-
ziness. Vestibular vertigo was defined according to diagnostic cri-
teria that had been developed for this survey through piloting and
validation in a specialized dizziness clinic (table 1). MV was de-
fined according to previously published diagnostic criteria for def-
inite MV
2
(table 1). Some patients with MV do not fulfill all of
these criteria, e.g., have an International Headache Society (IHS)
migraine but do not show typical migraine symptoms during the
vertigo attacks or do not have a history of IHS migraine but report
typical migraine precipitants for their vertigo or response to anti-
migraine medication. These patients can be diagnosed with prob-
able MV.
2
However, we did not aim to investigate the prevalence
of probable migraine in this study since this would have length-
ened the interview considerably as shown in the pilot study. Sim-
ilarly, the prevalence of non-vestibular dizziness related to
migraine such as orthostatic dizziness during migraine attacks
was not investigated. Migraine was diagnosed according to the
criteria of the IHS.
8
The interviews had a specificity of 94% and a
sensitivity of 84% for vestibular vertigo and 100% and 81% for
migraine as shown in a concurrent validation study (n 61). The
interviews were conducted by two medical student interviewers
(F.L., M.F.) who had been extensively trained in a neurotologic
dizziness clinic over a period of 1 year. Each interview was dis-
From the Department of Epidemiology (H.K.N., T.Z.), Robert Koch Institute; Vestibular Research Group (H.K.N., A.R., M.v.B., M.F., F.L., T.L.), Department
of Neurology, Charite; and Department of Neurology (T.L.), Schlosspark-Klinik, Berlin, Germany.
Disclosure: The authors report no conflicts of interest.
Received December 23, 2005. Accepted in final form May 12, 2006.
Address correspondence and reprint requests to Dr. H. Neuhauser, Robert Koch-Institut, Seestr. 10, D-13353 Berlin, Germany; e-mail: neuhauserh@rki.de
1028 Copyright 2006 by AAN Enterprises, Inc.
cussed with an experienced neurotologist (H.N., M.v.B., A.R., or
T.L.).
The prevalence of MV was calculated taking into account the
two-stage sampling design by multiplying the proportion of MV in
neurotologic survey participants with the proportion of dizziness/
vertigo in GNT-HIS participants.
3
Thereby, non-responders and
those lost to follow-up between the two sampling stages were
assumed to have the same probability of MV as participants of the
neurotologic survey. The CI for the prevalences were calculated
using the conservative Wilson method
9
and taking into account
the loss of power through non-response and loss to follow-up be-
tween the GNT-HIS and the neurotologic survey.
The analysis includes comparisons of participants with MV
and two different control groups of dizziness-free individuals from
the general population participating in the GNT-HIS. For the
analysis of the association of MV with demographic factors and
comorbid conditions we have chosen a control group of dizziness-
free migraineurs in order to avoid confounding by migraine (since
MV patients also all have migraine). Migraine was assessed in the
neurotologic survey and in the GNT-HIS 2004 but not in the
GNT-HIS 2003. Therefore, the first control group came from
the GNT-HIS 2004. Thirty participants with MV in the past 12
months were compared to consecutive migraineurs participating
in the GNT-HIS 2004 without vertigo/dizziness in the past 12
months (n 589). The GNT-HIS 2004 belongs to the same pro-
gram of nationally representative health interview surveys as the
GNT-HIS 2003, has the same sampling design, an almost identi-
cal response rate, and a migraine questionnaire based on the IHS
criteria. Both in cases and controls only visual auras were in-
quired about. The questions on sociodemographic factors and co-
morbid conditions were identical for the cases and controls.
Comorbid conditions were self-reported physician diagnoses ex-
cept for depression, which was self-reported by the participants.
Chi-square test and Fisher exact test were used to test for
univariate associations of categorical variables and the t test for
differences in means of numerical variables. Results were consid-
ered significant at p 0.05. To test for independent associations
with MV, we performed a stepwise backward logistic regression
analysis.
The second comparison focused on health-related quality of life
as measured with the eight-item short form questionnaire (SF-8).
The SF-8 is a generic instrument for measuring health-related
quality of life in the past 4 weeks constructed for use in
population-based studies.
10
The control group consisted of all
dizziness-free participants of the GNT-HIS 2003 subsample on
which the neurotologic survey was based (the GNT-HIS 2004 did
not include questions on health-related quality of life). Age-
adjusted SF-8 scores and 95% CI in all eight subscales and in the
two summary measures were compared for the 14 participants
with MV in the past 4 weeks and 2,816 dizziness-free controls
using a general linear model univariate procedure.
We additionally investigated the consequences of MV at the
general population level by asking about sick leave, overall impact
on daily activities, and health care utilization.
Results. We identified 243 participants with vestibular
vertigo, corresponding to a general population lifetime
prevalence of 7.4%. A total of 109 participants had a his-
tory of both vestibular vertigo and migraine, corresponding
to a general population lifetime prevalence of 3.2%. Thirty-
three participants had migrainous vertigo according to the
study criteria (27 women and 6 men). These were 14% of
all participants with vestibular vertigo and 3% of all par-
ticipants with moderate to severe dizziness or vertigo. The
lifetime prevalence of MV in the general population was
calculated at 0.98% (95% CI 0.70 to 1.37), and the 12-
month prevalence at 0.89% (95% CI 0.62 to 1.27).
The clinical characteristics of MV are summarized in
table 2. Vestibular symptoms were spontaneous rotational
vertigo (67%) or positional vertigo (24%) in the vast major-
ity of patients. Three participants (9%) reported recurrent
dizziness with nausea and either oscillopsia or episodic
imbalance. The most frequent migrainous symptom during
MV attacks was headache (91%). However, headache al-
ways accompanied vertigo in only 24% of participants.
Only 4 out of 33 participants with MV (12%) had vertigo
with the typical duration of an aura (5 to 60 minutes) and
in close temporal relationship to headache, and only in two
did the vertigo regularly precede the headache.
Cochlear symptoms during vertigo were reported by 12
patients with MV (36%) but none had progressive hearing
loss as would be expected in Menie`res disease. Sixty-one
percent noted at least one typical migraine trigger (men-
struation, stress, or sleep irregularities) for both their
headache and MV attacks.
Age at onset of MV ranged from 8 to 53 years (median
23 years) and MV attacks had occurred over a period rang-
ing from 1 to 48 years (median 13 years). Migraine head-
ache manifested before MV in 74% of participants and in
more than half of these (52%) migraine headache preceded
MV by more than 5 years, in 26% even by more than 10
years. The vast majority of patients (85%) had experienced
both active MV and active migraine headaches during the
last 12 months.
We analyzed the association of MV with sociodemo-
graphic factors and comorbid conditions comparing partic-
ipants with MV in the past 12 months with dizziness-free
migraineurs selected from the general population (GNT-
HIS 2004 participants) (table 3). In univariate analysis,
only coronary heart disease (CHD) was associated with
MV, while age, sex, education, migraine aura, stroke, dia-
betes, body mass index, hypertension, elevated blood lip-
ids, and self-reported depression were not. In a logistic
regression model analysis including age, sex, level of edu-
cation, elevated blood lipids, diabetes, and CHD, only CHD
was independently associated with MV and the association
of diabetes with MV was marginally significant.
Age-adjusted health-related quality of life scores were
consistently lower both in men and women with MV com-
pared to dizziness-free general population controls from
the GNT-HIS 2003 in all eight scales of the SF-8 and in
the summary measure scales. However, this comparison
had low power due to the few MV patients with vertiginous
attacks in the last 4 weeks (n 14) and the confidence
intervals are wide (figure).
Forty percent of working MV patients reported sick
leave from work. The overall impact of MV on daily activi-
ties was rated as mild by 21% of participants with MV, as
Table 1 Diagnostic criteria for vestibular vertigo and migrainous
vertigo used in the neurotologic survey
Vestibular vertigo (one has to be fulfilled):
1. Rotational vertigo
2. Positional vertigo
3. Recurrent dizziness with nausea and either oscillopsia or imbalance
Migrainous vertigo (AD have to be fulfilled):
A. Recurrent vestibular symptoms of at least moderate severity
B. Current or previous history of migraine according to the criteria of
the International Headache Society
C. At least one migrainous symptom during at least two vertiginous
attacks: migrainous headache, photophobia, phonophobia, or
visual auras
D. Not attributed to another disorder
September (2 of 2) 2006 NEUROLOGY 67 1029
moderate by 46%, and as severe by 33%. Impact was de-
fined as mild when activities during the days with MV
could be pursued, moderate when there was interference
with daily activities, and severe when daily activities had
to be abandoned.
Two thirds of participants with MV had consulted a
physician for their vertigo and almost all of them had
undergone at least one diagnostic procedure (table 4). Most
patients could report a diagnosis as the result of the con-
sultation. This diagnosis, however, was MV only in four
patients (21% of diagnoses). The others had been labeled
with non-vestibular diagnoses including anemia, diabetes,
cervical dizziness, psychosomatic dizziness, and hypovole-
mia. Forty percent of participants with MV had taken
medication for their vertigo but only one third reported a
good response.
Discussion. The main finding of our study is that
MV has a lifetime prevalence of approximately 1%
and thus is a frequent condition at the general popu-
lation level. This is in line with the high prevalence
of MV in specialized dizziness and migraine clin-
ics,
1,7,11,12
which however cannot be extrapolated to
the general population since the selection effects in
specialized care settings produce a considerable bias.
Another important finding is that migraine head-
aches and vestibular vertigo concur in the general
population about three times more often than ex-
pected by chance: at a lifetime migraine prevalence
of 16%
4
and vestibular vertigo of 7%,
3
chance concur-
rence is expected in 1.1% of the population but was
actually found in 3.2% of the population in our study.
Strengths of our study are the nationally repre-
sentative general-population setting, the use of vali-
dated neurotologic interviews for vestibular vertigo
with high specificity and sensitivity, and the use of
explicit diagnostic criteria for MV. In addition, we
sought to minimize misclassification by a detailed
assessment of the most common differential diag-
Table 2 Clinical characteristics in 33 participants with
migrainous vertigo (%)
Main vestibular Spontaneous rotational vertigo 67
sympton* Position triggered rotational
vertigo
12
Position triggered nonrotational
vertigo
12
Vestibular dizziness 9
Additional vestibular Oscillopsia 36
symptoms Imbalance 61
Vestibular head motion
intolerance
49
IHS migraine With visual aura 36
Without visual aura 64
Migrainous symptoms Headache
with vertigo Sometimes 67
Always 24
Photophobia
Sometimes 47
Always 16
Phonophobia
Sometimes 47
Always 9
Visual aura
Sometimes 36
Always 0
2 Migrainous symptoms
with vertigo
Sometimes 67
Always 12
Cochlear symptoms Tinnitus 15
with vertigo Aural fullness 15
Hearing loss 9
Typical duration 1 min 25
of attacks 15 min 22
560 min 22
124 h 28
24 h 3
Total no. of attacks 220 12
(lifetime) 21-50 50
50 38
Shared precipitants Menstruation 33
of migraine and MV Stress 41
Sleep irregularities 38
* Leading to the classification as vestibular vertigo.
Vestibular dizziness: recurrent dizziness with nausea and either oscillop-
sia or episodic imbalance during at least two attacks.
Percent of women with migrainous vertigo (MV).
IHS International Headache Society.
Table 3 Sociodemographic factors and comorbidity in 30
participants with migrainous vertigo in the past 12 months
compared to 589 dizziness-free migraineurs
Prevalence (%)
Migrainous
vertigo
Control
group
Univariate
p
Multivariate*
OR (95% CI)
Women 83 76 NS 1.7 (0.65.0)
Age, y, mean (SD) 43 (15) 38 (12) NS 1.1 (0.81.6)
Secondary school
education, y
NS
10 35 22
10 39 39
10 27 30
Migraine with
visual aura
33 26 NS
Self-reported depression
in the past year
19 18 NS
Hypertension 27 21 NS
Elevated blood lipids 31 21 NS
Diabetes 11 2 NS 4.8 (0.924.9)
Coronary heart
disease
15 2 0.01 4.4 (1.117.9)
Stroke 0 1 NS
Body mass index,
kg/m
2
, mean (SD)
25 (4) 24 (4) NS
* Backward stepwise logistic regression including age, sex, and all factors
with p 0.25 in univariate analysis, leading to a model including age,
sex, coronary heart disease, and diabetes.
The OR for age is reported for an increase in age of 10 years.
Self-reported physician diagnosis.
NS not significant at p 0.05.
1030 NEUROLOGY 67 September (2 of 2) 2006
noses of MV (BPPV, Menie`res disease, and ortho-
static dizziness).
As with any epidemiologic study, we cannot ex-
clude selection bias. However, the willingness of
GNT-HIS participants to undergo a further inter-
view was not associated with having dizziness/ver-
tigo. More importantly, non-responder analysis of
the neurotologic survey, which included a compari-
son of the GNT-HIS sample on which the neuroto-
logic survey was based with national population
statistics, showed very similar distributions of demo-
graphic features and selected health indicators (age,
sex, BMI, and smoking).
3
As an exception to this,
participants with a lower secondary school education
were underrepresented in the GNT-HIS, whereas
those with a middle and higher educational level
were overrepresented. Since vertigo has been shown
to occur less frequently in individuals with a higher
educational level,
3
the effect is likely to be an under-
estimation of the true MV prevalence.
The difference between the lifetime and the 1-year
prevalence of MV is surprisingly small and may be
due to recall bias, i.e., that more remote attacks of
MV may be more easily forgotten, in particular ac-
companying migrainous symptoms. This, however,
would result in an underestimation rather than an
overestimation of the true lifetime prevalence of MV.
With regard to recall bias, we refrained from includ-
ing benign paroxysmal vertigo of childhood, which is
an early childhood manifestation of migrainous ver-
tigo. Benign paroxysmal vertigo of childhood is
characterized by brief attacks of vertigo or disequi-
librium, anxiety, and often nystagmus or vomiting
that occur recurrently for months or years in other-
wise healthy young children.
13
Many of these chil-
dren later develop migraine, often years after vertigo
attacks have ceased.
14
In a population-based study,
the prevalence of recurrent vertigo probably related
to migraine was estimated at 2.8% in children be-
tween 6 and 12 years.
15
Our estimates of the prevalence of MV are also
likely to be conservative since both the validated in-
terview diagnostic criteria for vestibular vertigoas
a prerequisite for diagnosis of MVand the diagnos-
tic criteria for MV had an emphasis on specificity
rather than sensitivity. These prevalence estimates
do not include probable MV since identifying pa-
tients with probable MV would have involved inquir-
ing in detail about migraine precipitants of vertigo
and response to migraine medication, which was not
possible in the time frame of the interviews. How-
ever, probable MV is likely to be frequent as well. In
an earlier dizziness clinic case series, probable MV
accounted for a further 4% of diagnoses in addition
to the 7% of patients with definite MV.
2
In the neurotologic survey, 109 participants had a
history of both vestibular vertigo and migraine, cor-
responding to a general population prevalence of
3.2%. Based on a lifetime prevalence of vestibular
vertigo of 7%
3
and migraine 16%,
4
around 1% of the
population can be expected to have a chance concur-
rence of vertigo and migraine. We have found that
an additional 1% of the population has migrainous
vertigo, i.e., a vertigo syndrome causally linked to
migraine. It is likely that among the remaining 1%,
Table 4 Health care utilization in 33 participants with
migrainous vertigo (%)
Medical consultation 67
General practitioner/internal medicine 58
ENT 27
Neurologist 24
Radiologist 15
Orthopedist 9
Other 3
More than one specialist 37
Diagnostic procedures 36
Audiometric test 27
EEG 27
Brainstem auditory evoked potentials 21
Cranial CT or MRI 21
Caloric test 18
Ultrasound of carotid and vertebral arteries 12
Cranial or cervical X-ray 9
Cervical CT or MRI 6
More than one diagnostic procedure 30
Figure. Age-adjusted health-related quality of life in 14
participants with MV during the last 4 weeks compared to
a representative general population sample of 2,816
dizziness-free controls (short form eight item health status
survey [SF-8] scores with 95% CI).
September (2 of 2) 2006 NEUROLOGY 67 1031
there are quite a few cases of probable migrainous
vertigo. However, since other vestibular disorders in-
cluding BPPV and Me nie` res disease have been
shown to be associated with migraine,
16,17
the propor-
tion of patients with suspected probable MV cannot
be estimated from these figures.
We also aimed at investigating the association of
MV with sociodemographic factors and comorbid con-
ditions which have been previously linked to dizzi-
ness or vertigo. The choice of a control group of
unselected migraineurs from a general population
sample has the advantage of avoiding confounding
by migraine. However, the analysis had low power
due to the small number of cases and was limited by
the cross-sectional design and the assessment of risk
factors by self-report rather than measurement.
An interesting finding is that the proportion of
women did not differ significantly between partici-
pants with MV and dizziness-free migraineurs (83%
vs 76%). After adjustment for age and other factors
in multivariate analysis, the OR for female sex still
was not significantly different from one. This is the
first analysis of the association of sex and MV ad-
justed for migraine and suggests thatunless it is a
power problemthe female preponderance among
patients with MV merely reflects the female prepon-
derance among migraineurs in general.
The proportion of 33% MV patients with visual
auras seems rather high. However, it is not signifi-
cantly higher than in the control group of dizziness-
free migraineurs (26%). In addition, since well over
90% of migraineurs with aura have been reported to
have visual auras,
18,19
the overall proportion of mi-
graine with visual aura in the MV group probably
still lies within the range of reported proportions of
18% to 36% of migraine with aura from population-
based studies.
18,20
Of note, in the vast majority of
cases, MV misses not only the duration criterion for
an aura as defined by the IHS, but also the temporal
relationship to migraine headaches.
11
There was also no evidence of an association of
MV with depression, although previous studies have
shown an association of vestibular vertigo with de-
pression. However these studies did not exclude con-
founding by migraine.
3,21,22
Both the significant
association of MV with CHD and the marginally sig-
nificant association with diabetes are rather surpris-
ing and do not necessarily reflect a causal
relationship. Diabetes has been previously discussed
as a risk factor for peripheral vestibular
dysfunction,
23-25
but the overall evidence has re-
mained inconclusive. CHD was associated with non-
vestibular dizziness in previous studies
26,27
but not
with vestibular disorders. Of note, while migraine
was not associated with early onset CHD in several
studies,
28,29
this association has not been thoroughly
investigated yet among migraineurs with aura. In
addition, adult migraineurs, particularly those with
aura, had a higher cardiovascular risk profile.
30
Mi-
graine with aura however is unlikely to explain the
association of MV with CHD in our study since the
two groups do not differ significantly with respect to
visual auras and the overall proportions of migraine
with aura are likely to be similar as well.
In our analysis, the proportion of migraineurs
with aura in the MV group (33%) compared to the
control group (26%) may have contributed to the as-
sociation of MV with vascular factors, but cannot
explain it entirely.
We compared this unselected general population
sample of patients with MV with patients with MV
from our specialized dizziness clinic, who were diag-
nosed according to the same criteria.
2
The two
groups showed a similar age and sex distribution, as
well as a similar proportion of patients with sponta-
neous rotational vertigo and patients with migrain-
ous headaches in close temporal association to their
vertiginous attacks. However, neurotologic survey
participants with MV had shorter attacks than dizzi-
ness clinic patients with MV: 47% vs 18% had at-
tacks shorter than 5 minutes and only 3% vs 27%
had attacks longer than 24 hours. This may explain
why one third of survey participants with MV never
consulted a doctor for their vertigo.
Our results suggest that MV is not only a frequent
disorder but also has a considerable impact both at
the personal and at the societal level. The differences
in the age-adjusted quality of life subscales and sum-
mary measures consistently point toward lower qual-
ity of life in MV patients compared to dizziness-free
controls. As our results are based on a small sample,
they could be adjusted only for age. It would be inter-
esting to investigate health-related quality of life in
a larger group of patients with MV compared to a
control group of dizziness-free migraineurs and to
control for other comorbid conditions.
A 1-year population prevalence of 0.9% and a
medical consultation rate of almost 70% prompting
various diagnostic procedures in the majority of pa-
tients suggest considerable health care costs due to
MV. The low recognition rate of MV is worrisome
and confirms that MV is not a well-known condition
in primary care.
31
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MARK YOUR CALENDARS!
Plan to attend the 59th Annual Meeting in Boston, April 28-May 5, 2007
The 59th Annual Meeting Scientific Program highlights leading research on the most critical issues facing neurolo-
gists. More than 1,000 poster and platform presentations cover the spectrum of neurologyfrom updates on the latest
diagnostic and treatment techniques to prevention and practice management strategies.
For more information contact AAN Member Services at memberservices@aan.com; (800) 879-1960, or (651) 695-
2717 (international).
AAN 60th Annual Meeting in Chicago, Illinois
April 12-19, 2008
AAN 61st Annual Meeting in Seattle, Washington
April 25May 2, 2009
September (2 of 2) 2006 NEUROLOGY 67 1033