The Vestibular Migraine Community

Pathophysiology - Vestibular migraine


#1

They have FDG-PET scan image of the Brain during a VM episode in the below paper

Interesting snippet below for those who can’t read the entire paper

Apart from central mechanisms an inner ear involvement may explain some cochlear and peripheral vestibular findings recorded in certain patients. Trigeminovascular reflex-mediated vasodilatation of cranial blood vessels and subsequently plasma extravasation causing meningeal inflammation are the key features of pain in migraine [55]. The trigeminovascular system also innervates the inner ear [56]. In line with this hypothesis, Koo and Balaban demonstrated a protein extravasation in the inner ear and meningeal tissues in a murine migraine model [57].

Similarities with other paroxysmal disorders that often present with both migraine and vertigo, for example, familial hemiplegic migraine and episodic ataxia type 2, have been reported to be associated with mutations in the calcium channel gene CACNA1A [58], and defects of the ion channels have also been discussed to play a role in VM [4]. So far, however, it has not been possible to identify a genetic defect in the same region [59, 60].

In summary, migraine-related vestibular disorders like VM may be caused by enhanced excitability occurring during the processing of sensory information, which is due to a genetic susceptibility. The enhanced excitation induces interactions of vestibular and pain pathways on several levels, from the inner ear to the thalamus and cortical level.


#2

Good find. Interesting.

They say the inner ear is involved, but how do they prove the root cause isn’t the inner ear? They don’t seem to.

I still believe hydrops is a common factor with menieres patients suffering the most extreme version. The cause of hydrops varies too. As the paper reports 4 of the VM patients were found to have hydrops. As usual there are so blinkered they only discuss the possibility of migraine is causing those cases of hydrops. Where are the considerations of both physical trauma and possible chronic bio-chemical imbalances which might lead to mild hydrops over time which could create the circumstances needed for the neurological symptoms to surface?

Why do some people spontaneously get this condition then slowly recover from it? That’s not explained and I’d argue mild trauma might be a better explanation for that. Much easier to injure your inner ear than your brain I suspect as the windows represent four of the thinnest membranes in the body and two of them are connected to bones themselves linked to the ear drum!! So intuitively acute loss of perilymph would seem to have a relatively high probability (and may explain the acute symptoms of many cases of VN and labs) Once that happens the compliance of the Reissner membrane guarantees a degree of hydrops which for many remains asymptomatic but if bad enough leads to high enough pressure in the ear to cause all the complex symptoms of light headedness, dizziness and tinnitus.

Incomplete, myopic and biased! Typical neurology paper.


#3

Idiopathic hydrops is Meniere’s irrespective of degree of manifestation. Meniere’s as a whole is rare and migraine makes more sense considering the number of sufferers. The prevalence of MAV is about 1% compared to Meniere’s which is 0.05%.

There are numerous papers that discuss vestibular migraine. I don’t see a reason why a disturbance in the Vestibular ganglion cannot cause vestibular symptoms. This is the central processing center for all balance and supersedes even the ear. There are tons of brain disorders with dizziness as a symptom.

I understand your theory but i am not ruling out the migraine theory as well. If it can be triggered like a migraine, feels like a migraine and is treated like a migraine with migraine meds then we better call it a migraine.


#4

How do you conclude that?

Meniere’s seems to be a syndrome that involves hydrops but is distinct because it involves episodic hearing loss and degenerative low frequency hearing loss.

How does that rule out any other form of less severe Idiopathic hydrops? In fact it is well known a significant population have hydrops from unknown cause but are not considered to have Meniere’s. I wonder if some age related hearing loss is actually down to a form of age developing hydrops (which might explain tinnitus and HF loss in older people and indeed advice that reducing salt can help prolong good hearing).

But that’s another issue, it doesn’t feel like a migraine most of the time. Traditional migraines are not 24/7.

A vestibular attack does not feel like a migraine at all and I remember I was very disappointed that despite Ami blocking the migraines, I still have had several severe vestibular attacks whilst on it that didn’t feel migrainous at all.

These neurologists in this ‘camp’ are asking for us to make a huge stretch!:

  • Migraine is 24/7 - hypothesis - e.g. this is how they explain the tinnitus?!
  • Migraines cause huge blood flow changes - academically controversial hypothesis
  • Migraines cause hydrops - audacious new hypothesis - this smacks of modifying their argument in the face of evidence to the contrary!
  • Migraines start one day … because … genetics, must be! - hypothesis
  • Symptoms are a hallucination - inferred hypothesis
  • You get this kind of migraine as apposed to ‘normal’ episodic non-vestibular kind … because … well that’s not explained …

That’s an AWFUL lot of hypotheses! Hogwash!

The meds work, well - some of these may be helping to reduce the likelihood of electrical spasm. Others may have bio-chemical effects on the inner ear, and some modify pressures which may be exactly why symptoms are relieved as reduce the impact of the hydrops, perhaps.

To say the meds reduce migraines may be true, but WHY they ultimately reduce migraines may be because they address either the neurological end or potentially something to do with the ACTUAL root cause …

I’ve no doubt migraine is involved, but I just don’t buy this huge fantasy that it is causing all these symptoms.

So we seem to have two camps:

  • migraine causes everything
  • injury/pre-disposition -> hydrops -> pressure -> sensory noise/instability -> migraine

The first one seems a very lazy explanation devoid of anatomical detail, evidence and full of hypotheses.

It’s also an attractive story you can tell anxious patients so they feel it’s less threatening … funny that!


#5

James,

VM is a diagnosis of exclusion. Meaning the doc who gave you a VM diagnosis has ruled out PLF and Hydrops. It is at this point folks come to this site, telling them VM is hogwash and they have PLF or Hydrops is setting them up for anxiety and pain !

How is your hypothesis helping anyone on this site ? Every one of them has all the hearing and balance tests known to mankind and it all showed up normal and they got the VM diagnosis. They have seen multiple ENTs and Neuro-oto’s to get here only to be told by you their doctors know no better. What are they supposd to do with your theory ?

There is an important Mind-body connection, meds loose their potency if patients don’t buy in the diagnosis. Calling everything as windows damage and hydrops is myopic ! The inner ear windows are seated deep within the bone and injuring them is done through the ear drum or ETD dysfunction or whiplash injury. But not everyone needs one of this to have VM. I have spoken to so many people first hand and i am 100% sure they don’t have any ear injury.

Even when a paper shows you PET scan of the brain when VM is in progress you question the etiology. I am convinced that VM as a separate diagnosis does exist which does not involve ear injury. I have done my share of reading as well. Again who am I to diagree with John’s hopkins and Mayo clinic. There are no camps let the folks on this site form their own opinion.

Also what you had was not MAV but PLF. Your migraine was a co-morbidity. I feel the migraine when it comes on, i have eye pain, pulsating in my head, blurred vision and brain fog. This is not 24/7. These are the exacerbations which manifest once in a while.

Again we have been over this many times. If you go back and see the wealth of material from Scott’s time buried in the site you will see migraine theory is so true.


#6

To give them an explanation that makes sense, something convincing.

Not what i’m saying. I’m not denying there is a MAV/VM condition. The diagnosis as a class of condition makes complete sense. I have said this many times.

However, I’m suggesting that the root cause of ‘VM/MAV’ is not migraine, but possibly Hydrops. Doesn’t change the treatment necessarily, just feel the ‘migraine camp’ are completely barking up the wrong tree with the science. You know very well Secondary Hydrops has the same set of symptoms as reported by MAV/VM patients - don’t you think that is rather a big co-incidence?!

I’m not putting a figure on the number who have an ear injury - could be bio-chemical imbalance that leads to fluid imbalance, or other causes as yet unknown. But I believe determining if you’ve injured your ear is very difficult as you may not feel any pain - I didn’t. A simple flight in a plane when you’ve had stuffed up tubes can do it. Pulling out in-ear headphones too quickly can do it (see Hain). And then apparently Hydrops can take up to 10 years to develop, so you don’t make the connection … you go to the doc and he tells you you have migraine because he didn’t get this information and didn’t make the connection either …

Your paper states that hydrops has been found in patients with VM (and we’ve shared one before that you found) - there is the evidence - they can have hydrops - this is the paper you just posted!

I’m after the truth, just like everyone. I see something wrong here. I see people in positions of power telling people things that don’t make sense. People have a right to know what is going on with their bodies.

There are camps. Some doctors do not believe the migraine hypothesis. And neurologists appear to differ significantly from ENT’s in their opinion.

I had an ear injury that lead to IDENTICAL symptoms to someone who has been told they have MAV/VM. I’ve also responded to the same medication! I didn’t just have Hydrops symptoms + migraine - I had MAV! I have experienced all the symptoms described on this site, including the brain fog, the pulsating head, the stiff neck, the rocking, the swaying, the dizziness, the marshmallow floor, motion intolerance, imbalance - i could go on. I have had exactly the same condition, save I had it worse in some ways, like you i’ve had hearing loss and crazy tinnitus, though I don’t like to compare suffering.

Did I have ‘Migraine Associated Vertigo’? Yes I did! I had migraines and I had vertigo, there is some level of association - I had MAV! Does that title assume an aetiology? No, its an association not a causality.

I was not happy when my neuro dismissed my injury and her explanation sounded ridiculous - that I’d had a genetic mutation! Alarm bells went off at this point and I saw a big red flag!

Me having migraine is no fluke - its because its probably the very same aetiology causing the migraine.

The idea of migraine causing these symptoms is a position of belief, not proven science. It’s just a hypothesis.

I cannot believe that we have a movement which is telling people their predominantly audio-vestibular symptoms are migraine and not an ear issue + de-compensation - Its not unlike believing the world is flat!

This doesn’t prove causality is one way or another … its just showing up neurological symptoms, as expected - I would never refute there are significant neurological symptoms in this condition. Believe me, I’ve had them and some!

But just because people have migraines doesn’t mean migraines cause the migraines!!!


#7

What do you think causes migraine headaches in someone who doesn’t have dizziness? Do you think that is also ear-related?


#8

I think the best generic paper on the subject of migraine I’ve read is this:

To me migraines are induced by sensory upset. It doesn’t have to be the ears, could be the eyes or some other. The type of migraine might give you a clue as to the source.

I have a suspicion it could be any case where neurons are subject to pressure, e.g. glaucoma, or some kind of pressure on the brain stem which causes noise in the electrical signals - much like we experience when we have pins & needles or phantom pain when we have a trapped nerve.

But pins & needles and phantom pain don’t give us migraines, something additional is happening.

I think its about learning.

I think the brain is constantly cross referencing the inputs from different senses and modifying the weights on the inputs to the neurons to ‘tune’ the system. Compensation if you like. In a healthy person this involves minute changes over time and is never noticed. This involves a bio-chemical algorithm.

If one input is going particularly wild it might cause things to go awry with this learning algorithm and push it beyond its useful limits which ends up in an electrical spasm - it’s that electrical spasm which is a migraine. It’s a system which is normally stable but whose properties mean that it can go into positive feedback and instability in certain circumstances.


#9

I guess we just have to agree to disagree on the etiology of MAV.

I was reading a VM page by Dr.Purcell and he recommends electrolyte diluted 1/4 electrolyte to water for MAV folks. There are lots of studies for migraineurs need more salt 50% to 70% than regulars.I read the book Anna @Manatee referred on Amazon and it said the same as well.

This is quite the opposite of hydrops where you keep salt low.

I don’t think MAV and hydrops even have the same line of treatment. Diuretic affects brain chemistry as well as ear chemistry.


#10

I don’t restrict salt, I have Hydrops and I am still getting better.

One of the board members who has PLF has been told to increase salt intake, apparently. Perhaps this helps put pressure on the Reissner membrane to return it to balance?

I think salt restriction is recommended for Meniere’s sufferers mostly. And this highlights a problem facing medicine - too many doctors believe hydrops = Menieres and vice versa. There is definitely a spectrum of hydrops and possibly most of it is not Menieres. The prevalence of tinnitus is probably one sign of this.

I think the jury is out on whether it actually delivers benefits. Your kidneys should be maintaining the electrolyte level effectively. That makes me wonder if there is something in the management of blood electrolyte balance/hormone that is causing some of these issues for those with no injury.

What kind of migraineurs? You are running into trouble if you are too closely combining the vestibular population with the non-vestibular population. There is clearly a huge difference in the symptoms of these populations. Migraine is an outcome. What is the driver?

All this talk of migraine but no explanation of what is causing the migraine and why it differs hugely in its presentation into very clearly distinct categories. Yet another reason to be deeply skeptical.


#11

@GetBetter: Can you provide the link to that page (or give me a clue as to how to find it)?


#12

Maybe the driver IS migraine. I think that’s the million-dollar (or pound or Euro) question.


#13

How can the driver be migraine? What causes the migraine? (Hypothesis in that paper I shared) Migraine is an episode, an electrical spasm. That’s it. What’s kicking off that event?

How come sufferers go 30+ years without a migraine? Then …


#14

How come people go 50+ years without cancer? Then…


#15

Subject for another board I suspect. Just guessing, but doubt it’s linked …


#16

My point is that many illnesses develop later in life, so it stands to reason that migraine could also develop later in life in some people.


#17

Or whatever this is. But point taken.


#18

James a big hole in your theory is topomax and effexor and migraine meds don’t cure classic meniere’s. If it did folks won’t be calling meniere’s as auto immune variant. That tells you idiopathic hydrops is not same as migraines


#19

Menieres patients get migraines. Initially menieres is very episodic suggesting hydrops element is otherwise asymptomatic at least for first few years until imbalance becomes chronic.

Show me hi resolution inner and middle ear scans which prove inner ear is not involved during vertigo. ie inner ear is same as in healthy control. I don’t believe such scans exist unfortunately. Without that science your hypothesis goes no further than being that. We have to wait I guess.


#20

This is no hole and there is a good explanation for their effectiveness which is totally compatible with my hypothesis:

Changes in the inner ear (e.g. Hydrops) might be ‘compensatable’ if you control the migraine. Once you compensate for the additional sensory noise (assumption: all degradation introduces noise), the migraines and the dizziness go away as the brain has adapted. Some of the drugs will help calm the brain from going into migraine and intuitively this must help with compensation as it prevents the learning process from ceasing completely so adaption can take place. Hence why topomax and effexor are helpful. My core assumptions here are that migraine is an artefact of the adaption algorithm failing and that no useful adaption/compensation occurs during a migraine. Read the above paper for support on that theory. I trust you agree that topamax and effexor are blocking the migraines? because of this i would never argue with treating the migraine

You hear doctors talk of compensation, de-compensation and lack of compensation - what do you think that’s all about? Why do you need to compensate? Because of a change in the sensory information! MAV patients are offered VRT to help the brain compensate. By fully compensating you get rid of the migraine trigger!! This might explain why many get better and can get off the drugs - again more evidence that migraine is secondary as why else would they cease if the real trigger hadn’t been addressed? Why bother pushing VRT if migraines are the inevitable cause of ailment?

The “Auto-immune” story is hypothetical as well. It’s probably equally well explained by there being a global influence on bio-chemical balance in the inner ear - ie the hormone and electrolyte balance in the blood which would effect both ears. I raised this with my surgeon btw, and he agreed, this is a reasonable alternative explanation to the “auto-immune” theory as hormones and blood travel to both ears.