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Migraine-­associated Dizziness Over the past three years you have had approximately ten spells of vertigo, nausea, and vomiting. On ­ those days you spent most of your time in bed. By the next day the vertigo was gone. You have been very susceptible to motion sickness since childhood, and you have experienced migraine headaches since your early teens. You are sensitive to light and sound with some of the vertigo spells, but you ­ don’t have headaches. The observation that migraine and dizziness often occur together dates back to the nineteenth ­ century when Edward Liveing noted their connection in his classic book On Megrim, Sick-­ headache, and Some Allied Disorders. Liveing studied mathe­ matics and medicine at Cambridge and developed his “nerve storm” theory of megrim (migraine) in the mid nineteenth­ century. In a nutshell, he felt that migraine was similar to other paroxysmal neurological conditions such as epileptic seizures, vertigo attacks, and trigeminal neuralgia—­ all caused by a sudden discharge within the brain, a nerve storm. Although his theory on the mechanism of migraine has largely been abandoned, he provided a detailed description of symptoms seen in patients with migraine, including dizziness and motion sickness. Only in recent years have we recognized CHAPTER  4 Dizz y Spells with No Apparent Trigger 70 how common dizziness is in ­ people with migraine. Migraine-­ associated dizziness affects at least 1 ­ percent of the general population, and about two-­ thirds of ­ people with migraine headaches have a lifelong sensitivity to motion sickness. Dizziness can occur during headaches, but it often occurs during headache-­ free intervals. Only about one-­ quarter of patients usually experience headaches with their dizziness. Migraine-­ associated dizziness attacks typically last from hours to days, but ­ there can be a baseline dizziness that never completely goes away. If the person with migraine-­ associated dizziness is seen by a doctor during an attack, the doctor may note nystagmus with similarities to that of a person who has­ either an inner ear prob­ lem or a brain prob­ lem. We ­ really ­ don’t understand why patients with migraine are so prone to dizziness , nor do we understand the basic cellular mechanisms of migraine, with the notable exception of a few rare families with documented ge­ ne­ tic mutations. Migraine headaches and migraine-­ associated dizziness share many common features. Both are much more common in ­ women. Attacks of both migraine headaches and dizziness can be precipitated by changes in barometric pressure, lack of sleep, fasting, certain foods, and emotional stress. Many with migraine-­ associated dizziness have relatives with migraine headaches and dizziness. Moreover, medi­ cations that are effective for preventing migraine headaches are often effective in preventing migraine-­ associated dizziness. When we first suggest to a patient that their dizziness may be related to migraine, they typically are skeptical. “But I­ haven’t had a migraine headache for several years,” they maintain, or “I ­ don’t get headaches with my dizzy spells.” Our response is that migraine is not a headache. It’s a disease, a ge­ ne­ tic disease. The most common symptom is headache, but not every­ one with migraine gets headaches. Some may have Migr aine-­associated Dizziness 71 episodes of flickering lights in their visual field, called a visual aura. Headaches may follow, but sometimes the visual aura is the only recognizable symptom of migraine, often called ocular migraine. We frequently see ­ people who tell us, “I ­ don’t have migraine headaches, I have ocular migraine.” The real­ ity is that if you have any of ­ these migraine symptoms, you have the ge­ ne­ tic disease called migraine, and the challenge is to find ways to live with and manage the symptoms. Similar to ocular migraine, recurrent, spontaneous bouts of vertigo, nausea, or motion sickness may be a migraine-­ equivalent symptom that can occur with or without headache. Ge­ ne­ tic mutations that cause migraine have been identified in families with a rare variant of migraine, called hemiplegic migraine. ­ People in ­ these families have spells of numbness and weakness on one side of the body associated with headaches. ­ Others in the same ­ family have just migraine headaches with or without visual aura. The ge­ ne­ tic variants that cause more common types of migraine have yet to be identified, but ­ there clearly are multiple genes—­ some that increase susceptibility and ­ others that decrease susceptibility to developing migraine symptoms. The pattern of genes in the­ family determines which symptoms individuals ­ will have—­ visual aura, vertigo attacks, or just extreme sensitivity to...


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