Dr. Roach: Vestibular migraines include a balance element

Keith Roach
To Your Health

Dear Dr. Roach: Can you shed light on how vestibular migraines are diagnosed and the best treatment?

— J.H.

Dear J.H.: The vestibule of the ear is where the organ of balance is located, so vestibular symptoms relate to balance issues in general, but most commonly, it means vertigo. The term “vestibular migraine” means vestibular symptoms attributed to migraine.

Vestibular migraine thus includes migraine headache — not everyone will have headache with every episode, but most people with vestibular migraine will have headache with at least some of the episodes — and vestibular symptoms. These could include vertigo (a sensation of movement when still), unsteadiness or movement symptoms with a change in head position that persists long after the head has moved. Abnormal sensitivity to sound and vision are also prominent in vestibular migraine.

There is a similarly named condition, basilar migraine, that also has vestibular symptoms. However, basilar migraine has additional symptoms seen during the early, or aura, phase coming from the brainstem, deep in the brain, such as clumsy movements or confusion. These occur most commonly five minutes to an hour before the headache.

Making the diagnosis of vestibular migraine is challenging, since there are many clinical entities with similar symptoms. There is no conclusive laboratory or radiology tests to confirm the diagnosis. In practice, the diagnosis of probable vestibular migraine is made in people with recurrent migraine symptoms associated with vertigo. Often, treatment is begun when the condition is considered probable, and if the person does not respond well to treatment, a more thorough evaluation is considered.

Treatment for vestibular migraine is broken down into treatment for acute attacks and treatment to prevent attacks. Many neurologists use diazepam (Valium) and similar drugs for acute attacks. Preventive medicines come in many different families, and the choice of the best agent depends often on other conditions the person has. Everyone with migraine should try to find and avoid triggers. This includes eating on a reasonable schedule and good sleep hygiene.

If medications are needed, prescription choices include blood pressure medicines (beta blockers like propranolol and calcium channel blockers), antidepressants and seizure medicines. Over-the-counter options include riboflavin, magnesium, feverfew and coenzyme Q10, all of which have some but not conclusive evidence of benefit superior to placebo.

Dear Dr. Roach: Someone I know, who is a nurse, mentioned to me that she had Lyme disease about 15 years ago. She said her doctor at the time told her that if she gets it again she will die. Is this true? I would have thought some immunity would be gained once you have it. She is completely healed and said she has no health issues associated with it.

— D.S.

Dear D.S.: Lyme disease is caused by the bacteria Borrelia burgdorferi, and is spread by the deer tick. There are many manifestations of Lyme disease, including rash, many nonspecific symptoms, and late symptoms such as arthritis.

Death from Lyme disease is rare, and is usually a result of carditis, which is heart inflammation. This happens in about 1% of cases of Lyme disease. There were nine cases of fatal Lyme carditis reported between 1985 and 2018.

People who are treated early for Lyme disease, such as those get the classic bull’s-eye rash, do not get immunity to Lyme. However, people who have had Lyme long enough to develop arthritis do develop some resistance to future episodes. Unfortunately, we are still at least several years away from a Lyme vaccine.

I could find nothing to support a significant risk of death from people who get Lyme disease a second (or subsequent) time, so I think you can reassure your friend.

Readers may email questions to ToYourGoodHealth@med.cornell.edu