New York Headache Center

Migrainous vertigo seems to respond to intravenous infusion of a high dose of corticosteroids, according to a report in the latest issue of Headache by a group of Indian doctors.  Two of their patients had intermittent episodes of severe vertigo and two had chronic vertigo.  All four respond to infusions of 1 gram of methylprednisolone.  One require 3 infusions, one needed 2 and in another 2 vertigo stopped after a single infusion.  We routinely use corticosteroids for severe migraine attacks when other medications fail.  While occasional (once or twice a month) use of corticosteroids is relatively safe, frequent or daily intake of corticosteroids (besides methylprednisolone, these drugs include prednisone, prednisolone, and dexamethasone) can lead to dangerous side effects.  It is possible that oral corticosteroids will produce a similar effect as an infusion and may be worth trying when nothing else helps relieve the vertigo.

A blood pressure medication telmisartan (Micardis) was shown to be effective in the prevention of migraine headaches by a group of German researchers led by H-C Diener.  Several blood pressure medications have been proven to prevent migraine headaches.  The oldest category of blood pressure drugs, beta-blockers have the most evidence to support their use and two of them (propranolol and timolol) are approved by the FDA for the preventive treatment of migraines.  However, beta-blockers are not high on my list because they tend to cause more side effects than other blood pressure medications.  The most common side effects are due to excessive lowering of blood pressure - lightheadedness, fatigue, and fainting.  They also slow down the heart rate, which can make it difficult to exercise, while regular aerobic exercise is the first treatment I recommend to my headache patients.  Calcium channel blockers, such as verapamil, are not as effective for migraine prevention as they are for the prevention of cluster headaches and can cause constipation, swelling and irregular heart beats.  Another blood pressure medication, lisinopril which belong to the family of ACE inhibitors has also been shown to prevent migraine headaches.  The most common limiting side effect of ACE inhibitors is coughing.  A newer group of medications, which are similar in action to ACE inhibitors is ACE receptor blockers, or ARBs.  ARBs do not cause coughing and telmisartan which is one of the ARBs caused as few side effects as the placebo.

Vertigo can induce a migraine attack in migraine sufferers, according to a study published in Neurology.  In this study researchers induced vertigo in patients who had a history of migraines and in a control group.  Almost half of those who had a history of migraines developed a migraine attack within 24 hours, compared with only 5% of those who were not known to have migraines.  The study suggests that vertigo due to an inner ear problem can trigger a migraine attack.  This finding will not come as a surprise to migraine sufferers who cannot ride a roller coaster or even go on bumpy a car ride without getting a migraine.

At times, migraine sufferers develop vertigo as part of their migraine attack and it can be difficult to tell if vertigo caused the migraine or was just one of the symptoms.  A detailed description of more than one attack usually gives a clear answer.

Good news for adolescents with chronic daily headaches (CDH) was reported by Taiwanese researchers followed 122 kids, aged 12 to 14 who were diagnosed with this condition.  A year later 40% still had CDH, and after 2 years, 25% had symptoms of CDH.  They followed 103 of the original 122 for 8 years and found that only 12% still had daily headaches with 10 out of 12 diagnosed as having chronic migraines.  This is what we see in practice, but now we have good evidence and can be more certain when we tell our adolescent patients and their parents that they will “grow out” of their headaches.  Another piece of good news was that most kids were not actively treated and headaches improved on their own.  However, it may take months or years for headaches to improve and we should not just sit and wait while the child suffers.  Active treatment includes sleep hygiene, regular exercise, avoiding dietary triggers, biofeedback or relaxation training, magnesium, CoQ10 and other supplements, possibly acupuncture, Botox injections and medications.

In my post 2 years ago I wrote about surgery for migraines and the many reasons why Botox injections is a better option than surgery to permanently cut nerves and muscles.  I also wrote that there were no controlled studies to show that surgery actually works.  Now we do have one study.  The study was blinded, which means that some patients had nerves and muscles cut, while others had only a skin incision.  The results were much better in patients who had real surgery.  The plastic surgeons who performed the study tried their best to produce a blinded study, but they admit that blinding is far from perfect since patients who had real surgery can see their muscles shrink or not move.  But even if we accept that blinding was achieved and surgery indeed provides relief of headaches, all of my other arguments stand.  These include surgical risks (bleeding, infection, scarring, and persistent nerve pain) and high cost.  Yes, Botox is expensive too, but migraine usually is not a life-long illness and migraine attacks often stop for long periods of time or permanently with or even without treatment.  I have seen many patients whom I treated with Botox every 3 months and whose headaches stop after a year or two.  Two years of Botox treatments is significantly cheaper than surgery and it does not carry all of the surgical risks.