Differentiation of migrainous positional vertigo (MPV) from horizontal canal benign paroxysmal positional vertigo (HC-BPPV)

Abstract

This article presents an approach to differentiation of migrainous positional vertigo (MPV) from horizontal canal benign paroxysmal positional vertigo (HC-BPPV). Such an approach is essential because of the difference in intervention between the two disorders in question. Results from evaluation of the case study presented here revealed a persistent ageotropic positional nystagmus consistent with MPV or a cupulolithiasis variant of HC-BPPV. The patient was treated with liberatory maneuvers to remove possible otoconial debris from the horizontal canal in an attempt, in turn, to provide further diagnostic information. There was no change in symptoms following treatment for HC-BPPV. This case was diagnosed subsequently as MPV, and the patient was referred for medical intervention. Treatment has been successful for 22 months. Incorporation of HC-BPPV treatment, therefore, may provide useful information in the differential diagnosis of MPV and the cupulolithiasis variant of HC-BPPV.

Clinical aspects of benign paroxysmal positional vertigo associated with migraine

“…Symptoms that qualify for a diagnosis of vestibular migraine include various types of vertigo. Because the headache is often absent during acute attacks, motion sickness, positional or head-induced type of vertigo in migraine may present a diagnostic challenge with true BPPV 4,11 . Resolution of vestibular symptoms with anti-migraine drugs in patients with migraine-related vertigo as well as a need to initiate preventive therapy provides a challenge for the clinician for the differential diagnosis.…”

“…The origin of these deposits is claimed to be due to degeneration in utricular neuroepithelium, the incidence of which increases mostly with trauma, ischemia and vascular damage. Roberts et al 11 presented a patient with cupulolithiasis variant of horizontal canal BPPV who did not benefit from several attempts of liberatory maneuvers, but the patient got well after migraine therapy which raised a question of differential diagnosis and the possibility of co-incidence.Could migraine and BPPV share common pathological basis in patients with positional vertigo? If this is the case, do the clinical features in patients with BPPV and migraine differ from patients with BPPV without migraine?…”

Neuro-otology- some recent clinical advances

“…Persistent, geotropic direction-changing positional nystagmus, without latency, could originate from a “light cupula,” i.e., a cupula with a lower than normal specific gravity [23–25]—similar to that in phase 1 of alcohol-induced positional nystagmus. About 40 % of HC BPV patients have migraine with geotropic or apogeotropic nystagmus [22, 26–28]. Those of our colleagues who do not own an examination couch, can examine these patients quite well in a chair using the “bow-and-lean” test [29].…”

Positional Nystagmus in Patients Evaluated for Dizziness and Imbalance

“…Vertical nystagmus is common with CNS involvement [23], but horizontal nystagmus is also reported [6,7]. Five of these seven patients had either a direction-changing positional nystagmus or vertical nystagmus.…”

“…von Brevern et al reported a variety of types of nystagmus observed in various static positions: geotropic, ageotropic, torsional, and downbeat for patients with definite migrainous vertigo [6]. We have reported on ageotropic horizontal nystagmus in patients with migrainous positional vertigo (MPV) [7].…”