xRead - Episodic Vertigo (January 2026)

10976817, 2020, S2, Downloaded from https://aao-hnsfjournals.onlinelibrary.wiley.com/doi/10.1177/0194599820909438 by Mayo Clinic Libraries, Wiley Online Library on [19/09/2025]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License

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Otolaryngology–Head and Neck Surgery 162(2S)

Benefits: Accuracy of diagnosis, avoid unnecessary treatments or testing, potential for more appropriate treatment, patient education, promotes multidisci plinary care Risk, harm, cost: Extra time for assessment. Referral to other specialists. Benefit-harm assessment: Preponderance of benefit over harm Value judgments: None Intentional vagueness: None Role of patient preferences: Small Exclusions: None Supporting Text The purpose of this statement is to emphasize that the clini cal features of MD and VM overlap. As such, MD can be mistakenly diagnosed in patients who have VM. The mis diagnosis can lead to unnecessary testing, referrals, and treatments. This can inconvenience patients and delay symp tom improvement. Uncertainty about the formal diagnosis is common during the early course of symptoms and whenever the audiometric criteria for MD is not met. The 2 conditions can also occur concurrently. VM patients are typically younger and more likely to be female when compared with those with MD. A multidisciplinary panel has established diagnostic criteria for VM that require the current or prior history of migraine headaches (see Table 6 for diagnostic criteria of migraine) 73,74 and also migraine features (ie, migraine headaches, photo- or phonophobia, visual aura) with at least 50% of the vestibular episodes (see Table 6 and Table 7 footnotes a-c). 75 Conversely, MD should be diagnosed when the characteristic audiometric hearing loss is identified on audiograms, even when migraine features are present. 75 Reports of the similarities between MD and VM were found in Prosper Me´nie`re’s original writings. In his seminal work that implicated the inner ear in attacks of vertigo, Me´nie`re stated, ‘‘Persons who are subject to migraine often present symptoms analogous to those which we have described. . . . I have observed and pointed out this fact for a long time.’’ 76 Despite Me´nie`re’s observations in 1861, the general medical community has been slow to adopt migraine as a cause of vestibular/auditory symptoms. It took until the third edition of the International Headache Society’s classification of headache disorders—published in 2018—for VM to be officially listed as an episodic migraine syn drome. 74 Vestibular specialists, however, have long consid ered migraine to be a common cause of dizziness in specialty clinics, and survey research indicates that it is also common in the general population. 77,78 The slow adoption of migraine as a common cause of vestibular/auditory symptoms might relate to the previous use of other diagnostic labels, such as benign recurrent vertigo and vestibular Me´nie`re’s disease — which are now considered VM. 79 Migraine with brainstem Policy level: Recommendation Differences of opinion: None

limited to, vestibular schwannomas; note that strokes, tumors, and other neurologic problems that cause dizziness may not be characterized by acute spinning), medications (ie, blood pressure, diuretics, chronic vestibular suppressive medications), and family and social history (ie, tobacco, caf feine, recreational drug use, or herbals/alternative medica tions). Clinicians should also take a thorough history about possible diseases that can mimic MD that also present with fluctuating hearing loss, tinnitus, and aural fullness, includ ing VM, otosyphilis, and acute labyrinthitis. Since VM is a disorder that may closely mimic MD, it is important that evaluating clinicians inquire thoroughly about migraine in the patient’s past or current medical history (see KAS 2). In migraine, ‘‘hearing loss’’ may be a perception of difficulty processing sound, as opposed to hearing it, and auditory complaints in migraine are often bilateral. Clinicians should inquire about vertigo triggers that include light sensitivity and motion intolerance as well as any prior or ongoing treat ments for migraine or VM. VM may present with short ( \ 15 minutes) or prolonged ( . 24 hours) periods of vertigo duration. Visual auras are more likely to be described before, during, or after attacks, and hearing loss is mild or absent and stable over time. These last 2 symptoms, com bined with motion intolerance and light sensitivities in migraine, can help make the clinical differentiation from MD. The emotional impact of this condition should also be addressed and should not be underestimated. Patients often struggle with ongoing vertigo attacks and incapacitating tin nitus and hearing loss. Clinicians can provide welcomed assistance to their patients by providing reasonable treat ment expectations about recovery and duration of symptoms (see KAS 6 on patient education). STATEMENT 2. ASSESSING FOR VESTIBULAR MIGRAINE: Clinicians should determine if patients meet diagnostic criteria for vestibular migraine when assessing for Me´nie`re’s disease. Recommendation based on nonconsecutive studies, case-control studies, or studies with poor, nonindependent, or inconsistently applied refer ence standards with a preponderance of benefit over harm. Quality improvement opportunity: VM is a common cause of dizziness that can closely mimic MD. Appropriate assessment for VM could lead to more appropriate treatment. National Quality Strategy domains: Prevention and Treatment of Leading Causes of Morbidity and Mortality, Effective Communication and Care Coordination Aggregate evidence quality: Grade C, based on case control studies or studies with poor, nonindependent, or inconsistently applied reference standards Level of confidence in evidence: Low, studies were done in specialty populations and may not be gener alizable to more primary care populations Action Statement Profile: 2