Important case reports - Meniere's or MAV?

Hi All,

This is a very nice little paper which shows just how well MAV mimicks or is even possibly behind (a trigger?) for Meniere’s disease (MM). In these two women they presented with what any physician and probably a good bunch of neurologists would nail down as MM, yet look at what happened:

[size=130]Summary[/size]
Recent reports have focused on a possible association between migraine and Menière’s disease (MM); patients suffering from MM present a higher rate of migraine. In some cases, the clinical features of migraine-associated vertigo (MAV) may mimic the presentation of MM. The present report focuses on two cases of females with recurrent episodes of rotational vertigo, fluctuating hearing loss and tinnitus lasting from a few minutes to several hours; both cases also presented migrainous attacks. As a result of repeated cochleo-vestibular attacks, both patients presented a permanent low frequency sensorineural hearing loss. Preventive therapies for MM did not reduce vertigo attacks, while Topamax and aspirin treatment resulted in a significant reduction of both migraine and vertigo. Both the diagnosis of MM and of MAV rely on clinical history and both disorders lack a specific diagnostic test. In the early stages, differential diagnosis between MM and MAV is often very difficult; previous investigations focused on the possibility that subjects with migraine may experience all symptoms of MM, including sensorineural fluctuating hearing loss. In conclusion, a trial with prophylactic drug treatment for migraine might be suggested in patients with clear symptoms of migraine and recurrent cochleovestibular disorders.

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• Prosper Menière himself observed the association between MM and migraine.
• a higher prevalence of migraine in MM patients, variously reported at between 43% and 56%, while in the normal population it is 10%.
• epidemiology of both MM and MAV may underline a possible pathogenetic link between the 2 diseases.

• MAV is the main disorder capable of mimicking MM in its early stages. There is clinical evidence that migraine can damage the inner ear, causing permanent hearing loss or impairment of vestibular function. Some authors have hypothesised that MM may develop in an ear previously damaged by vasospasm induced by migrainous mechanisms.

— End quote

[size=130]Patient #1[/size]
• 42-year-old female, suffering from migraine with aura according to IHS criteria. The final diagnosis was made by a senior neurologist. The patient reported the first attack of migraine at the age of 20 years, which more typically occurred before menstruation, at a frequency of 1-2/month. Her family history was positive for migraine (mother and one of three sisters).
• patient reported recurrent episodes of rotational vertigo (about 1/month) lasting from a few minutes to 1-2 hours, often with a right ear fluctuating hearing loss. Migraine and vertigo never occurred together.
• She also reported the presence of tinnitus which increased before vertigo attacks.
• Caloric tests demonstrated a right sided unilateral weakness (26%) during caloric stimulation according to Freyss and the Head Impulse Test was positive on the horizontal plane with refixation saccades towards the left side.

[size=130]Patient #2[/size]
• 59-year-old female with a long history of migraine which began at the age of 23 and ceased at the age of 50, immediately after onset of menopause.
• Over the last year, she reported various episodes of rotational vertigo normally lasting for 2-3 hours with hearing loss on the left side. She reported increased hearing loss during vertigo. Audiometric examinations demonstrated a low frequency sensorineural hearing loss.
• Preventive therapy of md with betahistine 24 mg twice a day, salt restriction and increased water intake did not prevent vertigo attacks, which remained unchanged in frequency and duration in a 6-month follow-up.

— Begin quote from ____

Drug prophylaxis of migraine with Topamax 100 mg a day and aspirin (100 mg a day) produced a clear decrease in vertigo attacks, in both patients, in a 1-year follow-up.

— End quote

How bizarre that daily aspirin helped to fix them up (with Topamax) which is in contrast to what Nick Silver would say about a painkiller. Now I wonder if my head would feel any better on 100 mg daily?

So the take home messgae folks is that quite clearly a dx of Meniere’s has to be closely examined to rule out either a problem completely or maybe partially based on migraine. They offer the following for help in differential diagnosis:

• In the patient’s history, the report of only very short (seconds to less than 15 minutes) or prolonged (more than 24 hours) vertigo spells are more likely due to migraine rather than MM. Moreover, if the spontaneous spells of vertigo are associated with migraine features (phono- or photo-phobia), migraine is the probable source.
• In MAV, audiometric and vestibular anomalies are more typically mild in magnitude and stable over time rather than fluctuating.

Full text article here:

Scott 8)

Interesting case studies Scott.

If used as a prophylactic aspirin wouldn’t be for pain would it? I Googled and found the following;

http://www.headaches.org/education/Medications/Aspirin_and_Migraine

*For nearly a century, aspirin has been used to treat migraine and other headaches. Aspirin has several actions that make it useful for treating migraine. First, it is an analgesic or pain reliever. Secondly, it blocks or reduces inflammation. This action is controlled in the body in part by a series of chemicals called prostaglandin. Aspirin blocks the ability of the body to manufacture these compounds. Thirdly, aspirin reduces the ability of platelets to aggregate or stick together. The aggregation of platelets is important as it serves as the first step in the body’s ability to stop bleeding. It also plays a role in migraine attacks and other processes. In migraine, platelets aggregate, causing them to release serotonin into the blood stream, which eventually leads to the vascular actions and other effects of migraine.

In migraine preventive therapy, aspirin has been tried several times with some benefit. Previous studies used large amounts of aspirin in order to reduce the frequency of migraine attacks. Several years ago, a study was conducted among physicians to determine if low doses of aspirin would help reduce heart attacks. An additional finding of this study was a 10% reduction in the frequency of migraine attacks among male physicians taking low-dose aspirin. Currently the National Headache Foundation is providing funding to examine the benefit of low-dose aspirin in preventing migraine in female subjects.*

Also discussed here: http://findarticles.com/p/articles/mi_m1200/is_n7_v137/ai_8556715/

Vic,

— Begin quote from ____

An additional finding of this study was a 10% reduction in the frequency of migraine attacks among male physicians taking low-dose aspirin. Currently the National Headache Foundation is providing funding to examine the benefit of low-dose aspirin in preventing migraine in female subjects.

— End quote

Thanks for posting that info. In the paper they describe aspirin as a “disaggregant”. I had no idea what that meant so asked the prof in here an hour ago and he said it means that it prevents platelets from sticking together – one of the reasons it’s used to prevent heart attacks in people who have already had a primary event.

I had forgotten too that part of the migraine cascade involves platelets. I might try this for a week or two – just 100 mg of aspirin daily, maybe with an enteric coating on it – and see if it makes a difference.

Has anyone here on the board tried taking daily aspirin like this?

S

I was told about 10 years ago by a physician who specialised in neurology (and who correctly diagnosed me with chronic migraine, which I didn’t believe - what would he know etc) that taking three aspirin ASAP as a migraine came on was as good as (and much cheaper than) Immigran. He was quite clear the magic number was three. Also if you take too many Immigran you can sort of die, but aspirin is fairly benign.

In my own experience neither the three aspirin nor the Immigran have ever stopped a migraine. Perhaps they’ve shortened it/reduced the intensity but I don’t know. I haven’t RCT doubled blinded myself yet :wink:

I was not aware of the disaggregant mechanism - I thought the aspirin thing was based on the theory that migraines are caused by constriction of the blood vessels, a theory which I thought had been shelved…?

Vic

The most up to date paper on this:

[size=130]Low-dose aspirin for migraine prophylaxis in women[/size]
Cephalalgia 2001, 21(3): 175-183.

Summary
Although migraine is more common among women than men, the only two large, randomized trials of low-dose aspirin for migraine prophylaxis have been conducted in men. As part of the Women’s Health Study, an ongoing randomized trial of low-dose aspirin and vitamin E among 39 876 female health professionals aged 45 and older, 1001 women with frequent migraine attacks were assigned to 100 mg of aspirin every other day (n = 525) or aspirin placebo (n = 476). Migraine frequency, as well as severity, duration, and degree of incapacitation, were assessed by self-report on questionnaires 12 months and 36 months after randomization, and also by monthly diaries kept before and after randomization. Women assigned to aspirin reported small and consistent decreases in migraine frequency (59.6% vs. 56.4% assigned to placebo reporting improvement at 36 months; odds ratio 1.13, 95% confidence interval, 0.86–1.48), as well as decreases in severity, duration, and migraine-related incapacitation. These reductions were not, however, statistically significant. These data are compatible with a small treatment effect of low-dose aspirin in the prophylaxis of migraine among middle-aged women.

Mechanism:
Changes in serotonin concentrations have been implicated as a possible trigger for migraine, and aspirin may diminish serotonin-mediated firing of neurons in the hypothalamus and brain stem. The finding of activated platelets in migraine sufferers, while not consistently demonstrated, raises the possibility that regular use of a platelet antagonist such as aspirin may help limit or prevent migraine. Aspirin’s effects on the central nervous system may also be involved in migraine prophylaxis.

The results aren’t great and not significant in what appears to be a well-designed study. Interestingly, I know Christine has said that taking a painkiller keeps her from becoming dizzy.

Scott

— Begin quote from "scott"

The results aren’t great and not significant in what appears to be a well-designed study.
Scott

— End quote

Indeed. What a shame :frowning:

Scott, I tried daily small amounts of asprin for several months, soon after coming off 3 months of propranolol followed by 3 months of amitriptyline (I was off all other painkillers at this point). I found that the daily asprin (in the end just one tablet) was keeping quite a decent control of stuff. Unfortunately, after a while it affected my top stomach and now, I cant take asprin because of the stomach.

But yes, I do keep control of things most of the time on small amounts of painkillers throughout the day. For two weeks I was getting by nicely, on just one fifth of a veganin tablet and one quarter of a syndol. Its gone up now because I am always bad for a week after my B12 jab and my sleep is sooooo bad at the moment.

Thinking of asking for prothiaden again (mainly for the sleep!)

Christine

Just thought I’d let those know who might want to read this paper in full that it’s now online. See my first post above.

S 8)

Oddly enough that is how I began to differentiate between my diagnosis of meniere’s and the possibility that I had migraine instead: whenever I took ibuprofen as a preventative or treatment I got less or no dizziness (sorry Dr. Buchholz). Still works to some degree. When I shared this with my ENT who had given me the meniere’s diagnosis he was indifferent to this and seemed “married” to his diagnosis…and that is when I knew I would be better off seeing my neurologist instead. Fascinating stuff.
Thanks for the report, Scott
Gail

This was a very interesting message I got from Prof Steve Rauch this morning regarding this paper and Meniere’s misdiagnosis:

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“Yes, this is a ridiculously common scenario that I and others deal with nearly every day we are in the clinic.”

— End quote

Scott 8)

That’s very interesting.
I do wonder if many people with other balance disorders should be rediagnosed with MAV too? I think it’s good that this condition is starting to get more recognition. In a way, it can be better to have a MAV diagnosis as there is some hope of it being treated to some extent with medication and/or lifestyle changes.

think it works for dizziness??? not just pain?

chris

Hi Guys.
Just a quick note.
My cousin has normal migraine , she swears by asprin, pops it as soon as she see’s aura and it stops her migraine in it’s tracks.
I cant take it as I have an allergy to it.

jen

this article is interesting for many reasons and i think critically important for newbies searching for a diagnosis. although for me (and this sounds crazy, i know) it gives me comfort that well over a decade later and numerous treatments later, including one to destroy part of my inner ear, that my meniere’s diagnosis has been right all along. i have had the same neurotologist since 2001 and he is a rare gem in that he actually knows his stuff and acknowledges that mav exists and while he writes mav in my file, he says i am a classic meniere’s patient. this mav thing seems to be a relatively recent development. however, he sent me to a neuro for my migraines and the neuro says no, it’s not mav. :? nonetheless, i’m on mav meds. unfortunately, they are not helping with the dizziness.

my concern had been when i came out of my meniere’s remission and my main complaint was severe disequilibrium and balance problems so severe that walking was almost impossible, was should i pursue meniere’s treatments or mav treatments. at that point the symptoms overlap. my oto was very clear with me and told me that i essentially was in stage 3 of meniere’s and that my good ear and bad ear were battling each other constantly and my brain could not compensate. we needed to settle the bad ear down. so we did with the gentamicin injections. many months later, my balance is much, much better and i’m happy with the decision.

now, the dizziness remains and i think having mm and mav that i may just have to deal with it.