Congresso Nazionale del Cenacolo italiano di VERTIGINE …cenavest.altervista.org/pdfrelazioni/Congresso nazionale/Vertigine... · Congresso Nazionale del Cenacolo italiano di audiovestibologia

Congresso Nazionale del

Cenacolo italiano diaudiovestibologia

Chieti 24 e 25 giugno 2016

Presidente del Congresso: Prof. Adelchi CROCEResponsabile Scientifico: Prof. Giampiero NeriDipartimento di Neuroscienze e ImagingUniversità degli Studi “G. d’Annunzio” - Chieti-Pescara

VERTIGINE EMICRANICA

Diagnosi e trattamento

Mario Faralli

recurrent vestibular symptoms history of migraine temporal association between vestibular and migraine symptoms esclusion of other causes

Consensus document of the Barany Society and the International Headache society

Vestibular symptoms

Spontaneous vertigo including

-Internal vertigo- external vertigo

positional vertigo

Visually-induced vertigo

head motion-induced vertigo

head motion-induced dizziness

Notes

Vestibular symptoms

rated moderate or severe

Duration of episode

highly variable

Relation to migraine aura

time frame 5-60 min

- only a minority of patients

Comments

Relation to basilar type migraine

not synonymus less than 10% VM fullfill criteria

precursor syndromes of migraine met the same criteria both diagnosis

Relation to benign paroxysmalVertigo of childhood

Other symptoms

not included as diagnostic criteria

transient auditory symptomsnausea, vomitingsuscettibility to MS

Comments

Results of vestibular testing


Overlap with Meniere’ disease

both criteria for VM and MM

Response to antimigraine medication

commorbid psychiatricdizziness syndrome

Comments

Chronic vestibular migraine



Placebo responseMultiple drug effectsSpontaneous improvement

Management of Vestibular Migraine

Treatment of individual attack

Prophylactic treatment

Non pharmacological measures

Pharmacological prophylaxis

Vestibular rehabilitation

No controlledtrials

Case series

Retrospective studies

Observational studies







Adherence torecomendations

Acceptingdiagnosis

Vestibular episodestemporarily indipendent

of headache

Contradictory interpretationsof vestibular symptoms



promethazine metoclopramide dimenhydrinate meclizine

Prolonged attack

Acute antivertiginous and antiemetic drugs

Specific treatments

antivertiginous, antiemetic andsedating properties, nausea andvomiting associated with bothheadache and vertigo, motionsikness

triptans (sumatriptan) NSAIDs

drugs effective in treatingmigraine headache do not workas well for vertigo







Adherence torecomendations

Acceptingdiagnosis

Vestibular episodestemporarily indipendent

of headache

Contradictory interpretationsof vestibular symptoms




Frequent attacks

Inhibition of cortical excitation

Restoring nociceptive dismodulation



general recommendations

frequent attacks



Diet, sleep hygiene, avoidance oftrigger factors

anxietyvisual dependence confidence in the balance system

Studies have not investigatedreal effective

controindicazioni indicazioni

β-bloccanti

propanololoatenololo

broncopatie.-cardiopatie ipertensione

diabete-ipotensione tachicardia

Calcio-antagonisti

flunarizinacinnarizina

Ipotensione-tremore vasculopatia

Depressione-obesità Insonnia-ansia

antidepressivi

amitriptilinafluoxetina

Cardiopatia-epatopatia depressione

Prostata-rene

Tiroide-glaucoma

Ipotensione-epilessia

Anti-epilettici

Valproato sodicotopiramato

ASA-nausea epilessia

Tremori-rene

epatopatie

Give a diagnosis – Accept this dagnosis

Frequency of the attacks

Side effect profile

Considercomorbidies!


Do not ask fortreatment


Vertigo vs headache



FLUNARIZINE - CINNARIZINE

sedationWeight gain extrapyramidal side effectsdepression

Calcium antagonist


flunarizine 5 mg oral Retrospective analysis Baier B 2009

5-10 mg oral Retrospective, open label

Maione A 2006

5-10 mg oral Open-label De Bock 1997

cinnarizine 37.5-75 mg oral retrospective Taghdiri 2014

Decrease of duration, intensity,and frequency of episodic vertigo(p<0.01)


Prophylactic treatmentCalcium

antagonist

randomized control trial 48 patients with Definitive MV 12 weeks duration 24 patients received 10 mg flunarizine daily + betahistine 16 mg 24 patients betahistine 16 mg daily flunarizine (10 mg) is effective on vestibular symptoms



antagonist

retrospective open lable 24 patients with VM and 16 patients with BM Assessement of V and H attacks after 1, 2 and three months mean frequency of V and H per months were significantly reduced after three months of cinnarizine therapy



antagonist

prospective study 22 patients with definite VM association of cinnarizine (20 mg) and dimenhydrinate (40mg) one tablet twice a day-1 month repeated three times (1 month interval) control group lifestyle measures main outcome: vertigo and headache episodes before and after treatment decrease of vertigo (5.3 to 2.1) and headache (4.3 to 1.7) decrease of vertigo (3.5 to 2.2) and headache (2.6 to 2)



PROPRANOLOL- METOPROLOL

Ipotensione broncopatia cardiopatia diabete

Beta-blockers


Metoprolol 150 mg oral retrospective analysis Baier B 2009

100-200 mg oral retrospective analysis Maione A 2006

propranolol 160 mg oral retrospective analysis De Bock 1997

40-160 mg oral retrospective analyses Taghdiri 2014



Prophylactic treatmentBeta-

blockers

prospective, randomized, controlled clinical trial 64 patients with definite VM group P (40-160mg daily); group V (37,5-150mg daily) outcomes: DHI, VSS, n° attacks, BAI and BDI (before-after 4 months DHI (P<.001), VSS (P<.001), n° attacks (p<.001) BAI significantly decreased in both groups BDI significantly decreased only in group V



retrospective study 100 patients (median age 47, range 21-72 years) with D and P VM 74 patients with medical prophylaxis, 26 patients only lifestyle reccom. outcomes: duration, intensity and frequency of episodic vertigo outcomes: associated features all patients (MP) showed ↓ of duration, intensity and frequency of vertigo all patients (MP) showed ↓ of all associated features patients without MP showed only decrease of intensity of vertigo episode patients without MP showed only decrease of few associated features



Symptomsassociated

Drugprophylaxis

Lifestylereccomandations

Postural instability √ √

Nausea/vomiting √ √

Need of rest √ √

Photo-phonophobia √

Visual symptoms √

Headache √ √

Light-headedness √ √

Auditory symptoms √

Urge of urination, diarrhea

Brainstem symptoms √

Other CNS symptoms √


Prophylactic treatment anticonvulsivant

TOPIRAMATE- VALPROATE



Valproidacid

600 mg oral retrospective analysis Baier B 2009

600 mg oral cohort study - VOR Gordon 1993

topiramate 50 mg oral retrospective analysis Baier B 2009

50-100 mg oral Open label, chart review Mikulec AA


Prophylactic treatment anticonvulsivant

LAMOTRIGINE

•Effective in the treatment ofmigraine aura, isolated, aura

• Effective in Basilar type migraine

• lamotrigine was superior tovalproate in suppressing corticalspreading depression


Lamotrigine 75 mg oral retrospective analysis Baier B 2009

100 mg oral Retrospective , open label Bisdorff 2004 (**)

Lample 2005

Bogdanov 2010

D’Andrea 1999

D’Onofrio 2007


Prophylactic treatment antidepressants

• anxiety

• sleep disorder

• psychiatric symptoms prominent

Amitryptiline

Nortryptiline

Serotonin reuptake inhibitors

Psychiatrist or behavioural therapist


amitryptiline 100 mg oral retrospective analysis Baier B 2009

10 mg oral retrospective study Maione A 2006

nortriptyline 50 mg oral Open label-chart review Mikulec AA 2012


Prophylactic treatment Acetazolamide

• not effectiveVahedi et al. 2002

• effective (migraine with aura)De Simone 2005

• effective in genetic disorders related to migraineBirsdorff 2011


acetazolamide 500 mg/day Retrospective cohort Celebisoy N 2016

Its place in VM is stillto be established



Acetazolamide in vestibular migraine prophylaxis:A retrospective studyNese Celebisoy et alEur Arch Otorhinolaryngol 2016

retrospective study 39 patients 500 mg/day acetazolamide outcomes: intensity (vas) and frequency (n°) of vertigo attacks evaluation after three months treatment



Pre-treatmentheadache

Pre-treatmentvertigo

Post-treatmentvertigo

Post-treatmentheadache

0

2

4

6

8

frequ

enc

y

Seve

rity

(VAS)

Pre-treatmentheadache

Post-treatmentheadache

Pre-treatmentvertigo

Post-treatmentvertigo

0

2

4

6

8

10

Acetazolamide in vestibular migraine prophylaxis:A retrospective studyNese Celebisoy et alEur Arch Otorhinolaryngol 2016


Prophylactic treatment Meniere’s disease or migraine associated vertigo?

A trial with prophylactic drug treatment for migraine might be suggestedIn patients with clear symptoms of migraine and recurrent cocleovestibulardisorders


Prophylactic treatment Meniere’s disease and Migraine

data support a proactive role for cinnarizine in preventing vertigo spells,especially in MD patients with migraine.

decrease in vertigo spells from 9.4 to 3.8 (MD with migraine) decrease in vertigo spells from 6.8 to 5.9 (MD without migraine)


Vestibular rehabilitation Physiotherapy

retrospective case series 14 patients with (MRV) physical therapy exercise program (mean visits:4.9; mean duration: 4 months outcome measures (DHI, DGI, ABC) before and after treatment

Improvement in physical performance measures and self-percievedabilities


Vestibular rehabilitation Physiotherapy

anxiety visual dependence chronic dizziness

Furman et al. 2005


treatment recommendations for VM are similar to those for migraine with or without aurea

Some reccomandations are based on the authors experience

Anamnestic factors are rilevant for diagnosis

Anamnestic factors and functional aspects in the selection of patientswith migrainous vertigoFaralli et al.Eur Arch Othorhinolaryngol (2010) 267; 1157-1162

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Congresso Nazionale del Cenacolo italiano di VERTIGINE …cenavest.altervista.org/pdfrelazioni/Congresso nazionale/Vertigine... · Congresso Nazionale del Cenacolo italiano di audiovestibologia