Headache - migraine
This syndrome is considered to be of special value in the structure of neurological disorders. Because of this it is presented as a separate chapter in the NOASC inquiry. In many cases they are regarded to be related to vegetative distortion, this is presumably specific for the countries of Central and East Europe [421]. Among our patients it has been reported in 92,5% of patients. They are considered to be the result of the vegetative innervation and microcirculation impairments in the brain blood vessels. This syndrome in our patients has clear-cut paroxysmal dynamics like migraine attacks, without any domination of localization [400; 410]. The latter might witness the polymodal mechanism of the final sign structure formation of the symptom.
This data at once refuse all the possible discussions about the disorders, dominating in the area of vertebro-basilar or medial meningeal artery. Independent from the location the common features for all the patients have been headache paroxysms accompanied by the vestibular disorder. In the dynamics of the illness dizziness appears the first and cephalgy joins at the next periods of the disease.
Because of close morphological placement of vestibular nuclei, vagus nucleus and sympathetic nuclei complex, just here at this locus the centers of vascular tonus regulation, vestibular excitation might easily expand to the neighbor centers causing the vessel spasms: pressure increase in some head vessels, phenomena recorded with the help of blood pressure measurements, eye-bottom vessels observation, rheography, dopplerography. The idea of vestibular migraine as a substitute of dizziness is already long ago discussed in the literature. The vertigo episodes in children, which later during the life are transformed into migraine-like headache episodes are also enough reported in the literary sources [102; 420]. Syndrome of cephalgy in the patients, suffered the ionizing radiation appears after two years after the vestibular damage [399]. The same has been observed in the patients, who have had head trauma or severe intoxication episode [84]. All this might indicate the universal character of this syndrome in the structure of long lasting consequences of vestibular lesions.
We consider it to be an important finding the fact that during the Takahashi autorotation test in 1,9% of our patients there appeared the headache episodes. And though the percentage of such patients is not too high, nevertheless, it proves the principal possibility of headache attack during vestibular stimulation or dysfunction.
Out of the data presented it might be seen that in the patients discussed the cardio-vascular disturbances are present, they play important role in the disease structure, but they are not greatly expressed and they are not the primary, leading or principal reason of the whole complex of the symptoms. At the same time in the vestibular loading tests the principal primary leading role of the vestibular deficit has been shown [38]. It gives the argument to document the trigger role of vestibular dysfunction in the vegetative syndrome development. Many speculations about the pathogenesis mechanisms of the phenomenon might be proposed, starting from the most primitive: overexitation of the MVN and DVN might expand to the vegetative nuclei involving internal organs like “vegetative storm” [399]. It is not excluded that it is developing like kinetosis, but in the chronic type of development. In this case vestibular disorder, which does not have significant cortical manifestation slowly causes neurotization and somatization with clear vegetative component. The latter appears because of exhausting of inhibitory feedback, starting from the 3 type of the neurons in the rhomboid fosse. The hyperreactivity (overexcitation) we have seen during caloric test expands the close zones resulting in vegetative symptoms occurrence. It is necessary to pay special attention that these vegetative symptoms appear to be extremely resistant to therapeutic procedures and often results in the invalidity of patients [414]. This knowledge provokes us to try the drugs, recognized to be effective for the vestibular system, for treatment of the vegetative disorders described. If they appear to be effective - we have the right to speak about vestibulo-vegetative projection as special structure in the brain of the living beings.
Migraine
Large epidemiological study based on the criteria established by the International Headache Society has revealed that nearly 18% females and 6% of males between ages 12 and 80 met the case definition for migraine headache. The direct correlation of low income and high incidence of migraines is reported [161].
The word itself comes down from Greek hemicrania, meaning one side headache, which might be complicated with nausea, vomiting and even consciousness losses [404; 411]. Besides scientific and clinical migraine identification, there also exists it medico-legal one. In some countries the established migraine diagnosis means that the treatment expenses are covered by the state or assurance medicine, while headache is paid by the patient himself. The influence of the assurance money into the migraine problems from one side complicates and from the other side provokes its scientific investigation [114]. That is why we are studying migraine problem in the wide meaning of word and not only as hemicrania.
Migraine classification in IDC-10
G43.0 Migraine without aura (common migraine)
G43.1 Migraine with aura (classical migraine)
Aura without headache
Basilar
Equivalent
Family hemiplegic with:
Aura with acute start
Prolonged aura
Typical aura
G43.2 Status migrainosus
G43.3 Migraine with complications
G43.8 Other types of migraine
Ophthalmoplegical migraine
Retinal migraine
G43.9 Migraine unclassified
In the classical type of migraine with aura the headache is precursed by 15-30 minutes aura or prodrome. Its typical version is visual one with positive (teichopsia, photopsia) or negative (scotomata or blind spots) visual phenomena. Positive phenomena usually appear simultaneously in both eyes, but sometimes asymmetry is also reported. Most frequently the positive phenomena occur which consists of teichopsia or fortification spectra: jagged zigzags of mostly white light, but might be of any color, rarely multicolor. Photopsia is manifested in the form of flashes of light, white or colored points, stars, sparks, simple or complex geometrical patterns, either constant or flickering, beating cilia or shimmering as if looking through the falling water. Negative visual phenomena might be manifested by gray and black spots (scotoma): hemianopsia, quadrantanopsia, tunnel vision, asymmetric field deficits, multiple scotomata, altitudinal defects, and monocular blindness. They might appear at the periphery, increasing gradually and sometimes occupying the whole visual field up to total temporary blindness. If the positive and negative visual phenomena are combined, the term scintillating scotoma is used. Visual disturbances such as micropsia or macropsia - decreased or increased size of the subjects percepted - belong to rather rare reports [161, 368].
Other typical forms of aura are somatosensory manifestations. Numbness, giddiness, tingling, as the forms of paresthesia, are starting usually from the ends of the fingers, then moving up the hands and legs to the abdominal part and, at last, are concentrating around the mouth area. The inverse dynamics of the symptoms is sometimes possible.
Dizziness and vertigo are found in about 60% of migraine patients, according to Profs. Hood and Kayan data [204]. They also reported the distribution of vertigo in the headache reference: in 15% of cases vertigo immediately preceded headache, in 36% it appeared in the headache-free interval, and in the other 47% - during headache. The authors have also noted that dizziness occurs very frequently in the migraine patients, but it is also common for other types of headaches, like tension headaches or cluster headaches. From the other side vertigo has prevalence to the severe headaches and is considered to be characteristic feature of basilar migraine. According to the data of Pyykko I. (2001) up to 70% of population suffers from the migraine of vestibular origin.
Basilar migraine is similar to the migraine with aura, but it is accompanied with basilar artery ischemia symptoms. The subjects of this disturbance are adolescence girls in whom migraine attacks occur premenstrually and are often associated with stupor, loss of consciousness and neurootologic symptoms. Basilar migraine means migraine with aura but the episodes must contain at least two of the next signs: visual symptoms in temporal and nasal fields of both eyes, diplopia, vertigo, tinnitus, hearing decrease, ataxia, dysarthria, bilateral paresthesia, bilateral paresis and decreased level of consciousness. The origin of the symptoms mentioned is ischemia of the basilar artery and its branches and terminals supplying blood to brainstem, cerebellum, cranial nerve nuclei and occipital lobe cortex [161].
Migraine without aura is sometimes more discussible nosology. The simplified criteria for its establishing are: unilateral side, throbbing quality, nausea, vomiting, photophobia and phonophobia. The diagnosis can be made when repeated headaches are associated with at least two of the symptoms named [349].
Migraine aura without headache might sometimes cause many misunderstandings. Among the patients there are two groups: in one aura might be or might be not associated with headache, in the other only aura is present being not associated with headache. They discuss migraine as a substitute of vertigo attack in the patients with vestibular dysfunction [102].
Besides classical types of migraine disorders, there are also some rare forms of the disease, described by separate authors. Prof. A. Shulman is considering tinnitus related to temporomandibulae joint disturbances as migraine manifestations [337]. Prof. Alund includes into the discussion sphere cervical migraine - headache with coordination disturbances, appearing while head turns without the occlusion of cervical arteries [8]. Well known are the associations of migraine with Meniere disease and allergies. In the central location of the vestibular disturbances headache episodes are revealed as the substitute of vertigo in children. Instrumental differential diagnostics of migraine is reported in the chapter, dedicated to vestibulo-vegetative disorders (cephalgy).
Differential treatment for migraine
Therapeutical procedures might be rather different, in which pharmacotherapy is prevailing. The gold standard for pain relief has long time been ergot alkaloids - ergotamine being effective in 90% of cases. Unfortunately, its side effects have seriously limited its usefulness. Nowadays serotonin receptor agonists appear to be effective in oral form up to 73% of patients and in intravenous injections - up to 90% of cases, is considered to be the golden standard. The migraine symptoms are eliminated in 10-30 minutes after the injection [161].
In the prophylactic therapy beta-blockers have demonstrated their effectivity in reducing the frequency and prevention of the spells in 50 - 70% of patients according to the data of the different authors. Usual adult dose is in the range of 80-120 mg per day, the effectiveness reveals after 5-6 weeks of therapy.
In the cases of the established vestibular dysfunction histaminic agonists appear to be of extreme effect. It appears to be especially effective in the cases, if the headaches are associated with dizziness and vertigo, giddiness (pseudovertigo), nausea and vomiting episodes, sometimes convulsions and consciousness losses. One month of such treatment is enough to eliminate the whole symptoms complex [411]. Positive effect has been reported in over 80% out of 47 patients studied in 1999-2001. Usually, it is better to pass the three months prophylactic treatment for the total relief of the symptoms. Among the most unpleasant complications, might be caused by the drug is the provocation of visual aura (without associated headache) in the patients with visual aura. The patients refuse treatment in these cases.
In the latter patients effective appear to be histamine receptor blockers. Thee have been proposed to be used during 3 months. Out of 149 patients 85% reported almost total release of headache spells. The effect has been monitored from 3 months to 1,5 year after the treatment and appeared to be stable enough. Some of medications are especially effective in the case of frontal (from 38 to 12% of patients), others and especially temporal (from 24 to 2% of patients) location of the pain. The positive effect appears to be less in the cases of occipital headache.
In the case of occipital headache the calcium blockers are effective. In 19 patients tried calcium blocker has decreased the percentage of patients complaining of this location migraine attacks from 42 to 9% of patients.
Conclusions
- Migraine headaches in many cases are the manifestations of vestibular disorders.
- Migraine might be instrumentally documented with the help of pupillometry.
- Vestibular disorders might be documented with the help of VestEP, nystgmography, cranio-corpo-graphy and their complicated and simplified modifications and also cardiography with vestibular loading tests.
- Medicaments correcting vestibular function are effective to release headache spells; their effect is long lasting.
- It seems reasonable to identify vestibular migraine into separate nosology G43.4.