Meniere’s, Migraine, or Both?

vertigocausessymptoms
image-809
When vertigo starts many are caught between two very different diagnoses. Vestibular Migraine, also known as Migraine Associated Vertigo (MAV) and Meniere’s Disease. These two conditions are both tricky to diagnose, and the two conditions occur in different parts of the body and require different forms of treatment.

Vertigo can have a lot of different definitions ranging from dizziness to experiencing the entire world spinning1. For the purposes of this article full or partial rotational vertigo refers to either the perception that all senses of the body are spinning or some of them. Full rotational vertigo in this article, and in most doctor’s offices and articles refers to vertigo where vision, the sensory system, sometimes even hearing, feels like it is perpetually spinning, usually in one direction.

Ménière’s Disease

Meniere’s Disease is believed to be fluid and inflammation of the inner ear which impacts the vestibular system and hearing.  Meniere’s is usually an ongoing chronic illness which can cause permanent damage to hearing and vestibular system in the affected ear. Meniere’s disease is a condition of the inner ear and is best treated by a neurotologist2.

Typically upon onset of the disease only one ear is impacted, overtime it can spread to the other ear, though this is typically after years.

Meniere’s requires it’s own dietary changes, often daily use of a diuretic, sometimes oral steroids, and often procedures done to the ear ranging from steroid injections to surgically destroying the balance center of that ear. Due to the long term consequences of untreated Meniere’s disease, as well as the potential need for destructive treatment, an accurate diagnosis is very important.

Early symptoms of Meniere’s disease often involves a feeling of fullness in one ear, muffled hearing in that ear, tinnitus in that ear, and often full rotational vertigo. Meniere’s vertigo attacks tend to be clearcut. Once they start they don’t tend to stop until they are done. Meniere’s vertigo attacks can last 20 minutes to over several hours. Meniere’s attacks also don’t tend to have triggers for individual attacks.  However, various biological and environmental factors can trigger development and recurrence of the disease.

Vestibular Migraine / Migraine Associated Vertigo (MAV)

Vestibular Migraine / Migraine Associated Vertigo (MAV) tends to occur in those who already have a history of migraine. Migraine is frequently misdiagnosed so many discover that headaches that they have had for years get diagnosed as migraine when they develop MAV. Migraine and MAV are neurological conditions, and are best treated by a neurologist that specializes in migraine5.

MAV can occur outside of a migraine headache or migraine aura. MAV has a broader definition of vertigo that includes rocking, a feeling of floating, disequilibrium, dizziness, even lightheadedness. However, full or partial rotational vertigo, a sense of fullness in one or both ears, and tinnitus in one or both ears can also occur. MAV attacks tend to have transient symptoms, essentially even if attacks last for over an hour the symptoms may fade in and out and change in intensity. Many MAV episodes are actually brief lasting seconds to minutes, but can occur many times a day and be disabling in their own right.

MAV is treated the same as regular migraine, except that for many abortive migraine treatments (usually triptans6) often do not work for the vertigo attacks themselves. Treatment for discrete episodes actually tends to be similar to Meniere’s included medications for nausea, benzodiazepines7, and meclizine8.

However, ongoing episodes of MAV often need preventative treatment. This usually means making lifestyle adjustments to regulate daily schedule, reduce stress, stay hydrated, and eliminate food triggers. For many medication also needs to be involved. Unfortunately the current understanding of how migraine preventatives work and the etiology of migraines is poor.

The better headache specialists tend to prescribe by comorbid conditions. If the patient has anxiety or depression they might used an SSRI, SSNRI, or a tricyclic. If the person has issues with blood pressure they might use a calcium channel blocker, etc.

The Differential for Ménière’s and MAV

Meneire’s usually impacts one ear. Attacks are often preceded by ear fullness, some loss of hearing and tinnitus, then full rotary vertigo usually lasting 20 minutes to 6+ hours with little slow down or change during the attack duration. Meniere’s attacks also have no known trigger, they just happen. The ear fullness, tinnitus, etc often follows a predictable pattern. If Meniere’s is present over time there will likely be detectable hearing loss in that ear, and often damage to the vestibular system of that ear.

MAV often effects people who already have migraine. Vertigo attacks can involve just dizziness, a floating feeling, and can also involve episodes of full rotary spinning. Headaches are not always present during an attack. Attacks are short several seconds to several minutes, or intermittent. 

Example: A period of sharp spinning for a minute, then floating, then nothing than spinning. MAV attacks are often triggered by light, parallel lines going in the horizon, head movement, and movement across the visual field. There can also be tinnitus, ear fullness, and this can be in one or both ears. There is typically no long term hearing loss or permanent damage to the vestibular system.

In Regards to Testing: Often for both conditions a range of tests are done for vertigo, primarily to test for the presence of nystagmus12 (involuntary eye movement often present in vertigo), hearing tests, MRI (really only as a rule out for other conditions like MS), and other measures. However, none of these tests can firmly rule out either condition, at best they can rule them in.  Nystagmus is often present in Meniere’s and MAV but only during an attack, and most medications prescribed for MAV and Meniere’s, preventative or acute, dull or eliminate the nystagmus response13.

A loss of hearing can rule in Meniere’s Disease, but this needs to be documented over time as both conditions can cause short term hearing loss. Often both diagnoses need to be developed through a careful patient history, patient interview, and tracking patient progress on their treatment plan.

My current headache specialist does not want me to get any further vestibular testing (like VNG) since I can’t do the medication washout period, or even the test without risking a major setback with my migraines. He does two brief in office tests for my vestibular function one being the Dynamic Visual Acuity test14, which I totally bomb.  As well as the Head Impulse Test15 which I totally bomb on the right side, but do perfect with on the left. My neurologist’s opinion is that this is likely due to permanent damage to my vestibular system on the right side from Meniere’s. So for chronic migraine sufferers facing testing those are some other potential testing options that are less detrimental to migraine treatment. HOWEVER, these tests may not be helpful in early diagnosis of Meniere’s and/or MAV, I likely test this way since I had a bad episode of Meniere’s which did the damage prior to this test being done.

My History, updated 2/17

I’ve had middle and inner ear problems since birth and migraine with basilar aura since age 13. A little over a year ago I developed full blown vertigo with some very long violent attacks of everything spinning and some very short attacks lasting seconds to minutes triggered by how I turned my head, movement across my visual field, lights, parallel lines, etc.

It is believed that my migraines went supernova chronic, and I developed Meniere’s due to wild hormone fluctuations from Endometriosis treatment, and the development of extremely severe allergies courtesy of the wild hormone fluctuations caused by Endometriosis treatment.

However, when the vertigo started I had no clue what it was, it even took a few days to recognize it was vertigo and I was so disoriented by the entire experience and was in near constant vertigo of some form of another within a week of symptoms starting. This made diagnosis extremely complicated.

Initially, I had a positive ECOG16 in the right ear, however all the nystagmus testing was confounded by not being able to do the full dry-out period on the medications.

A month in I started with a neurotologist2. At this point my migraines had become chronic again, I was allergic to all but one diuretic, and many of my attacks of vertigo were of short duration.  So I was diagnosed with MAV, referred to Neurology, but was to be followed since it was still possible I had Meniere’s.

After a month long course of steroid treatment for chronic migraine and MAV the world had stopped spinning enough for me to differentiate between attacks. I was having both short attacks with clear triggers, like fast motion in my vision, and longer attacks. The long attacks started to show a very specific pattern. A sense of fullness in the right ear, followed by low range tinnitus, muffled hearing, and then violent full rotational vertigo lasting at least an hour.

At this point I was diagnosed with possible Meniere’s. A few weeks later when the same type of attacks began to happen pretty much daily for 1 to 6 hours.

My Meniere’s was treated with steroid injections through the affected eardrum which stopped my 6 hour long violent vertigo attacks. I maintained remission for about a year, though in 7/15 I began having attacks again and they returned to the 6+ hour daily attacks by August. I was treated again with intratympanic steroids and thankfully again reached a state of remission. During this time I started showing low range hearing loss on my hearing tests and my diagnosis was changed to definite Meniere’s. In early February I unfortunately began having Meniere’s attacks in my left ear (the good ear), along with attacks in my known Meniere’s ear. My current neurotologist with Johns Hopkins thankfully believes in early intervention and I was able to get bilateral intratympanic steroid injections.

My migraine treatment has been a sordid affair since I have migraine with aura, MAV, chronic migraine, and a history of intractable migraine and status migraine. Back in August 2015 I was started on Lamictal and it worked! Since that time I’ve had next to no migraines, and my MAV had greatly improved.

I’ve been fortunate enough to have both an amazing neurologist and neurotologist. Both doctors agree I have both conditions, and use the same criteria. My neurologist during my initial visit actually detected signs of massive vestibular damage on my right side and said, “Oh there’s the Meneire’s!”  So I’m pretty confident with my docs’ conclusions. I am lucky to have them both and both work to better educate their peers on proper diagnosis of these two conditions together or separate.

The Takeaway

If both MAV and Meniere’s are in the mix for a potential diagnosis it is important to find doctors who are able to carefully pick apart the symptoms, provide you with proper education, and identify a treatment plan that is appropriate. My personal opinion is that if Meniere’s is even suspected it is extremely important to be followed by an Neurotologist that specializes in vestibular disorders, since the disease can, and usually does, cause permanent damage to the affected ear.

It is also really important to track symptoms, triggers, and in that also track the progression and timing of various symptoms. There are some classic patterns (though not all of us are classic!) that can help discern what is likely Meniere’s, and what is likely MAV.

References

One Comment

  1. Dizzy Chick

    March 9, 2017

    a great post S!
    I didn’t know that MAV is often short. I was told there was no way to tell if vertigo was caused by Meniere’s or MAV. You gave me new information.

    Thank you for giving us your story too.

Share Your Thoughts

To Comment: click the lock, and when it turns green press the Submit Button.