I’ve transcribed a discussion with Robert Baloh on a whole range of issues dealing with migraine, MAV, and medication. Baloh spends most of his time in research, particularly cutting-edge genetic research, and sees patients only twice a week. There’s a quite a lot here and, what really surprised me, was his use of Citalopram – one of his favourites for migraine. First time I’ve ever heard that from a neurologist! He does not like using multi-pharmacy for migraine because there is no evidence to back it up.
– most thorough migraine research (genetics) is happening in Finland under A Palotie who just completed a large study isolating a new gene.
– the trouble is we’re only just learning and understanding what migraine is and the factors that cause it. Most ENT doctors don’t have a concept at all about this.
– the first thing to realise is that migraine is not just a headache. Migraine is a genetic disease; headache is the most common symptom but only one of many symptoms. Vertigo is the second most common migraine symptom after headache. Headache and dizziness do not occur together and is one of the mysteries of migraine.
– most patients studied by Baloh who have been told they have Meniere’s in fact have MAV. ENTs tend to think that recurrent vertigo is Meniere’s because that’s all they tend to know about in this case. MAV is by far much more common than MD.
– Migraine never goes away because it is a genetic disease, however the symptoms do come and go and it will likely lessen over time. Hormonal factors in women are very important and as women age, symptoms will likely lessen more and more. This is very characteristic of the disease. Hormones are the biggest trigger in women – tips the balance and BAM, symptoms kick in.
– there are triggers for migraine symptoms: stress, lack of sleep, eating patterns, certain foods are MAJOR triggers but these are NOT the cause. The cause is a gene or some combination of genes. Some migraineurs have single gene disorders. People under stress in this group have had spells while others were fine even though they definitely had the gene mutation.
– whatever a person does, say with coffee intake, or sleep, it must stay consistent (assuming coffee is not a personal trigger). If you drink 1 cup per day, don’t suddenly have 3 cups one day.
– re the migraine diet: if you can identify an obvious trigger, avoid it. This is common sense but do not become a fanatic where you are not able to eat anything as this will not do you any good. In most people the diet is a minor issue and people identify certain triggers but to go on a rigid extremely limited diet is not useful.
– pinning down a specific food trigger is very difficult because it can often be a number of factors. Chocolate may be a trigger while under stress but is otherwise not. The number of triggers can be huge in this way and so Baloh therefore focuses on the MAJOR triggers which are sleep, and eating patterns (spreading meals out over time). Avoiding aged cheeses, red wine, hot dogs, MSG is a good idea because of the nitrites they contain (not MSG).
– there is no consistent damage to the inner ear with migraine. This is a chemical thing, with some alteration in the channels of the inner ear. There are “normal” times but other times it’s triggered off and is therefore abnormal. This notion we have of a damaged ear and the brain will compensate is incorrect. It cannot do that. If it’s damaged it’s transient and then goes back to normal and there’s no need to compensate any longer (true for vestibular neuritis but not MAV). Most migraine patients, in-between attacks, are perfectly normal. Vestibular function returns to normal.
– the ENG and VEMP tests are very crude and not particularly sensitive. Clear damage from VN will generally show up in such tests. The caloric test is very crude with a 30% variance still being classed as normal. Nobody gets a perfect zero response on a caloric. Just about everyone falls into the 10–20% range.
– Baloh has seen people with MAV who have a persistent illusion of tilt going on. Sometimes a sudden tilt or it may be persistent. This symptom is more likely originating in the brain and not the ear – i.e. it’s a chemical and not a structural problem. The tilting is perceptual and if tested, such a person would come up as performing normally. So it’s common in migraine to have illusions of motion and illusions of tilt (bouncing too).
– Citalopram (Cipramil/ Celexa) is one of Baloh’s favourites for migraine. In genetic studies, migraine and depression run together and so the same drugs are effective for both. The problem is there are no controlled studies for any drug in migrainous vertigo but there are lots for migraine headaches. Drugs like Celexa have been shown very consistently to be effective for decreasing frequency and severity of migraine headaches in controlled studies.
– a big problem is nobody can agree on how to define migrainous vertigo; nobody wants to take the effort to do the work on this – it’s very difficult work. It’s a big job. The drug companies aren’t enthusiastic … when it is defined is hard to say at this point.
– we know things such as barometric pressure can trigger an attack; people have an altered area in the brain where visual motion is processed … fluorescent light is a known trigger. Vision in the periphery is processed differently.
– about 25% of people with migraine will have vertigo attacks and about 2/3 have visual motion sensitivity.
– Important to understand what we’re dealing with. It’s a life-long susceptibility and certain things trigger it at certain times. Very often we can see the headaches get much better and the vertigo attacks become much worse and then it can reverse back again. They’re not the same thing (headache and dizziness). The truth is we don’t even know what the headaches are or what causes migraine exactly. There is a lot of mystery to this … you may ask how can this be when it’s so common but sometimes it’s the common ones that are the hardest ones to crack. 10% of the population has migraine; that’s 1 in every 10 people … it’s a highly prevalent disease. What other disease do you know that affects so many?
– There are several genes involved in some with more rare or severe syndromes. Sometimes medications can cause symptoms to totally disappear and sometimes they vanish spontaneously. Baloh is convinced the medications make a difference but be clear that none of these meds are “cures”. All we know is that they cut down on frequency and severity by 50% on average when they are effective. There is no evidence that any medication “resets” the brain. When you go off the meds, sometimes the symptoms don’t come back which is yet another mystery.
– Do not get into the habit of looking for endless doctors once you have the diagnosis because it can feed into the cycle. Accept the diagnosis. It’s natural to always wonder and look for a more definitive answer. Focus on lifestyle changes: sleep, eating patterns, regular exercise, vigorous exercise, meditation or other relaxation techniques. The medications are just a help as well; they’'re not the full answer.
– the question of whether multiple drugs cuts down further on frequency is really something we don’t know. There’s no evidence in prescribing multi-pharmacy for migraine. Baloh is hesitant to do so because you start to get into issues of interactions. Baloh would like to see evidence that even one drug works for MAV. Before considering more than one he would like to see just one working over a period of time. If Baloh had the answers to this right now, he’d be the only one because nobody else does. People can certainly try things (multi-pharm) but be careful because there can potentially be short term and long term side effects. Again, having a 50% reduction in symptoms is a very good outcome because there will also be spontaneous remissions as well. Baloh is cautious with multi-pharmacy because he has little experience with prescribing this way nor has he seen data to support it. He certainly does see increased side effects.
– Baloh not happy with seeing daily use of Xanax. Taken daily will create a dependence and tolerance problem, but OK once in a while.
– Sound sensitivity and/ or nausea very common with this condition.
– If a drug is reducing symptoms by 50%, stay with it, give it time and work on lifestyle to knock out the rest. Do not work under the notion that by just finding the right medicine that this will suddenly all vanish. Sometimes switching to a different drug in the same class can give more benefit (SSRI for example). It’s remarkable that even though all of the SSRIs work by the same principle, the results can vary markedly between individual SSRIs. Again, if we hit the 50% mark in symptom reduction then we’ve hit on a good drug. If there’s no effect or very little then we do a lot of switching between meds. The problem remains that there isn’t good data on treatment and it’s mostly empirical (observation, experience, or experiment) and that’s why many doctors have differing opinions and a different experience. It’s dangerous for a doctor to base his treatment based on his experience alone because any single doctor will have limited experience and is usually biased (confirmation bias). What we need are a large series of controlled studies which unfortunately just don’t exist.
– Difficulty in eye focusing is a common migraine symptom as is variable amounts of dizziness throughout the day.
– Propranolol causes fatigue and can trigger depression… a number of side effects.
– There is no data on and tremendous variability in the age where this peaks or drops off. It can happen at any time … no one knows.