Okay guys, get ready for another boring one, but for those of you who didn’t feel like reading the entire article, it really is filled with some gems:
**migraine is characterised by interictal alterations in neurochemicals (including serotonin, norepinephrine (noradrenaline), and dopamine) **and cutaneous allodynia, representing aberrant neurophysiology during migraine.11
These changes in monoaminergic activity due to vestibular activation may both trigger migraine related symptoms and
modulate activity in both pain related and anxiety related pathways.
Numerous studies have confirmed that anxiety and dizziness are interrelated.6 32 For example, among 268 patients
recruited from a tertiary otolaryngology clinic, panic disorder was identified in 17.2% and major depressive disorder in
11.2%.33
Based on a retrospective chart review of 132 (77%) of 172 patients at a tertiary dizziness clinic who had been referred for psychiatric evaluation, Staab et al40 classified patients into three groups: (a) psychiatric disorder causing dizziness,
(b) primary otoneurological disorder with secondary anxiety, and (c) preexisting anxiety or prodromes escalating
as a result of the neurotological disorder.
Anxiety seems to be a particular problem in patients with acute vestibular disorders. In a recent study,41 17
(57%) of 30 patients with acute vertigo reported that anxiety symptoms seemed disproportionate to the seriousness of
the disorder. Only 23% had no anxiety. The increase in anxiety was not just a general reaction to having an acute
illness, because the comparison group of patients with other acute neurological conditions without dizziness reported
significantly less anxiety (17%).
**The actions of selective serotonin reuptake inhibitors (SSRIs) have provided compelling evidence for a role of serotonergic transmission in vestibular function. **Recent evidence indicates that SSRIs are efficacious in the treatment of vertigo;18 32 72 furthermore, the beneficial effect of benzodiazepines such as clonazepam on both dizziness and anxiety
may be mediated by their serotonergic effects. 73–75 In addition, the vestibular manifestations of the SSRI discontinuation
syndrome (acute onset of dizziness, vertigo, and uncoordination) are exacerbated by head and eye movements, 76 77 which is consistent with direct effects on vestibular information processing.
**The link between migraine and balance disorders and the link between anxiety and balance disorders suggests that a subgroup of such patients will manifest migraine, anxiety, and a balance disorder. **MARD is unlikely to be simply the
chance combination of a balance disorder, migraine headache, and anxiety. This notion is supported by the increased prevalence of panic disorder in migraine patients with and without aura. In a recent study, the lifetime prevalence of panic disorder was 19.6% in migraine patients with aura and 14.3% in migraine patients without aura.84 In addition, the presence of anxiety in patients with migraine suggests a worse prognosis.85
The clinical implications of the overlap between migraine, anxiety, and balance disorders in MARD relate to diagnosis,
clinical course, and treatment. Because the care of these patients tends to be distributed among primary care physicians,
neurologists, otolaryngologists, and psychiatrists, the initial diagnosis may reflect the background of the examining doctor in addition to the symptoms of the patient. Furthermore, patients may self select to a particular specialist depending on which component predominates. Patients with MARD may be misdiagnosed if one or more components go unrecognised. In
our experience, balance symptoms in patients with a clinically significant anxiety disorder are most likely to be overlooked, as their symptoms are often attributed entirely to anxiety. An awareness of the existence of MARD will enable physicians not only to appreciate the predominant complaint but also stimulate them to look for the other components.
A common feature in MARD is visual dependence—that is, an excessive reliance on visual cues for balance. Visual
dependence and its symptomatic expression, SMD, affect many patients with migraine, anxiety, or a balance disorder. Patients with SMD often have discomfort in visual environments that are overly complex or devoid of visual orientation cues.
In certain anxiety disorders, particularly in height phobia, patients have an increased tendency to manifest discomfort in certain visual environments. As noted in figs 224, visual dependence and SMD may be seen in patients with migraine related or anxiety related dizziness, and in MARD.
if MARD represents a disorder in which the three manifestations constitute different symptomatic expressions of the same pathological substrate, a treatment directed at that underlying common pathological substrate should result in improvement of all three components. However, treatment directed at a component that constitutes a superficial manifestation of the condition (symptomatic treatment) should result in improvement of that component but not the others.
Although empirical information on the simultaneous effects of treatment on the three components of MARD is lacking, studies that focus on two of the three components have been conducted. With respect to the combination of dizziness and anxiety, several drugs, including antidepressants and benzodiazepines, are used to treat both conditions. Treatment with SSRIs may reduce both dizziness90 and posturographic abnormalities in agoraphobia.91 Dizziness limited to panic attacks in
panic disorder (psychiatric dizziness)92 resolves as panic frequency is reduced with treatment of this condition. In our
laboratory, we have found that vestibular rehabilitation therapy can be of value for patients with agoraphobia with
vestibular dysfunction who did not respond to behaviourally oriented therapy. 93 With respect to the combination
of dizziness and migraine, both abortive and prophylactic migraine medications effectively control headache and balance
symptoms in patients with both migraine and balance complaints.94 Reploeg and Goebel found a reduction of at least 75% in the frequency of attacks of dizziness in 72% of patients with migraine related dizziness who were treated with either a tyramine restrictive diet alone or diet in combination with nortriptyline or atenolol.95
In our experience, patients with MARD in whom balance symptoms predominate should be treated with a combination of an antidepressant, such as imipramine, and a benzodiazepine, such as clonazepam. Sertraline and diazepam are alternates. For patients in whom vertigo is considered a migraine aura or migraine equivalent, a triptan may be beneficial94 for acute
attacks. Patients with MARD in whom migraine predominates may also benefit from treatment with an antidepressant.
Our preferred medication is imipramine. This type of patient may also benefit from treatment with an anticonvulsant
such as topiramate or a calcium channel blocker such as verapamil. Note that in our experience, beta blocking agents do
not appear to be helpful for patients with MARD. Rescue therapy includes short term benzodiazepines. For patients with MARD in whom anxiety symptoms predominate, an SSRI such as paroxetine98 99 or sertraline90 is preferred. Benzodiazepines such as clonazepam are valuable, particularly for those patients with both prominent anxiety and pronounced balance symptoms
all patients with MARD, especially those with SMD, may benefit from vestibular rehabilitation therapy.
So Jen, can you top this one? :mrgreen:
I can’t claim to have any better handle on understanding this than anyone else researching this. But I think there is something to the MARD vs Migraine concept, and this COULD influence which drugs are given initially which COULD help to lessen experimentation and help to hit the nail on the head a bit sooner by having the proper mechanisms of action nailed down before treatment. (the following is just an example not an established protocol)If this turns out to be right, treatment could look something like this maybe… If it’s MARD, treat with SSRI/benzo first, and if not getting full results, add perhaps verapamil or another migraine preventative to take care of the secondary migraine disorder. If primary migraine, start with any migraine preventative, if no results, add second migraine preventative, if insufficient, add third category, if insufficient, add klonopin, if insufficient, add effexor (which covers anticonvulsant, calcium channel blocker, benzo, and anti-depressant). There’s not too much else one can do beyond that, but it does eliminate someone with MARD starting with say topamax first or verapamil first, where the primary problem is being left untreated. The same would hold true for a true migraineour who is started on say paxil first, with THEIR primary problem being left untreated. Sounds nice in theory anyway lol.
