Objective test results in Migraine, with an emphasis on dizziness and hearing testing.
Timothy C. Hain, M.D. • Last updated:
June 16, 2018
Migraine is a cluster of symptoms, and at least as of 2018, has no definitive "objective" test. Because migraine is not homogeneous, it is probably impossible for this to ever happen either. However, we do have a collection of laboratory tests that have been reported in migraine, and presumably these test results correlate with some of the symptoms of migraine. Our take on this is that we think that individuals with migraine are basically normal people, and thus most of these papers suggesting that this or that test works, are false positives. There is a selection bias in academics -- it is difficult to get a paper published unless it says something novel. This means that the publishing process selects for papers that are invalid. Perhaps this is why so few academic papers are reproducible.
One would generally expect that patients with migraine would be normal with respect to their vestibular testing, or perhaps a little better than normal, in as much as many of them are unusually sensitive to motion as well as many other sensory inputs.
ENG and Rotatory chair testing
- Bir et al (2003), reported that "Fifty-eight percent of the patients with migraine and 55% of the patients with migraine + vertigo had abnormal ENG findings. None of the tests except the Dix-Hallpike manoeuvre had a statistically significant difference between the two groups. " This small study would suggest there is more positional nystagmus.
- Celiker et al (2007) reported that treatment for migraine with valproate had no effect on their ENGs. This seems pretty reasonable.
- El-Badry et al (2017) reported positional nystagmus -- purely upbeating or purely downbeating in about 100% of 13 patients. We think 100% is a little high, but agree that there is more pure vertical nystagmus in patients with migraine.
- Harno et al (2003) reported that "most of the patients with migraine (83%) showed abnormalities in at least one of these tests. " Thies included either video oculography, electronystagmography, posturography, and audiometry. We are dubious regarding the significance of this observation.
- Mora et al (2009), reported " The presence of a VVOR nystagmus homodirectional to VOR indicates the absence of the optokinetic system prevalence due to a central nervous system (CNS) modification and highlights a CNS disease.". This was an investigation of 20 children with benign paroxysmal vertigo of childhood. We are dubious.
- Oh e al (2009) reported a single case of GEN and rebound. This is plausible but it is just one case.
- Polensek et al (2010) reported that 26 patients had various kinds of nystagmus, including 100% with positional nystagmus, going in nearly any direction. We think this is reasonable, but not especially specific.
- Togli et al (1981) stated "Utilizing labyrinthine tests with the aid of electronystagmography, abnormalities of labyrinth function were demonstrated in 80% of patients with common migraine who had no history of vertigo or of other otological and neurological disorders." We do not agree with this statement.
- Thompson-Harvey and Mikulec (2018) reported that 34 patients with vestibular migraine had total responses in the "lowest quartile". We are a bit dubious about this and think that it might reflect a small study size or perhaps migraine patients are suppressing their responses because of greater motion sensitivity.
- Vitovic et al (2008) reported that nasuea and emesis (vomiting) was more frequent after caloric testing in patients with migraine. This was a large study (523 patients), and we agree that patients with migraine are more likely to have distress, including vomiting.
- Von Brevern et al (2005) reported on 20 patients with migraine, and noted "Pathological nystagmus was observed in 70% of patients during acute MV: six had isolated spontaneous nystagmus, five had isolated positional nystagmus and three had a combination of the two" This is reasonable and similar to Polensek's findings. Of course, it is not common to be doing an ENG on someone having an acute migraine.
Salviz et al (2016) reported that "cVEMP differentiated MD patients from VM and healthy controls with asymmetrically reduced amplitudes on affected ears with low response rates at 500 Hz TBs, and alteration of frequency dependent responses at 500 and 1000 Hz TBs. These findings suggest that cVEMP can be used as a diagnostic test to differentiate MD from VM. " We are very dubious as cVEMP amplitudes are "all over the place" in our practice.
Chang et al reported 50% abnormality in children with benign paroxysmal vertigo. We find this difficult to understand, and we wonder if there was difficulty with getting children to cooperate.
One would generally expect that patients with migraine would be normal with respect to their hearing sensitivity, or perhaps a little better than normal, in as much as many of them are unusually sensitive to sound as well as many other sensory inputs. Thus we would expect that all of these papers would be false positives.
Audiometry and OAE testing
Hamed et al (2012) reported "Fifty-eight patients with migraine and 40 healthy subjects were assessed using routine diagnostic audiometry along with transient evoked otoacoustic emissions (TOAEs), distortion product otoacoustic emissions (DPOAEs), and auditory brainstem response (ABR) at high and low repetition rate frequencies. RESULTS: Nearly two thirds of patients with migraine had one or more abnormalities in electrophysiological testing. Compared with control subjects, patients reported significant lowering of TOAEs amplitude at frequencies of 1 kHz (right: P = .0003; left: P = .002), 3 kHz (right: P = .025), and 4 kHz (right: P = .019); prolonged wave III latency (right: P = .009); and I-V interpeak latency (IPL) (left: P = .024) at high repetition rate frequencies." We are doubtful that this has any meaning.
Joffilly et al (2016) reported that "women with migraine and phonophobia exhibited deficits in OAE suppression, which points to a disorder affecting the medial olivocochlear efferent system. " They said that TEOAE suppression was lower in migraine. We are not sure what to make of this.
Bolay et al (2008), provided somewhat similar results concerning absent suppression, suggesting that "In patients with migraine ..., mean amplitudes of TEOAEs were not suppressed by contralateral sound stimulus (P > 0.05).
Battista (2004) reported that "Three patients in the migraine-associated dizziness group had an elevated pure-tone average (>/=26 dB) and/or low-frequency pure-tone average at initial and/or follow-up assessment. CONCLUSION: Audiometric findings of patients with migraine-associated dizziness are most often normal. " We think this is very reasonable.
Dash e tal (2008), suggested that ABRs were often prolonged. We are dubious.
Vollu et al (2017) reported that "No significant difference was observed between migraine and VM patients with respect to audiometric and tympanometric measurements." This seems reasonable to us.
Vollu et al (2017) reported that "EcochG data suggests average SP/AP scores of VM patients are significantly higher than migraine patients. " As ECOG testing is technically difficult, we are dubious that this observation will translate into clinically meaningful results.
- Battista, R. A. (2004). "Audiometric findings of patients with migraine-associated dizziness." Otol Neurotol 25(6): 987-992.
- Bir, L. S., et al. (2003). "Migraine patients with or without vertigo: comparison of clinical and electronystagmographic findings." J Otolaryngol 32(4): 234-238.
- Bolay, H., et al. (2008). "Subclinical dysfunction of cochlea and cochlear efferents in migraine: an otoacoustic emission study." Cephalalgia 28(4): 309-317.
- Celiker, A., et al. (2007). "Effects of valproate on vestibular symptoms and electronystagmographic findings in migraine patients." Clin Neuropharmacol 30(4): 213-217.
- Chang, C. H. and Y. H. Young (2007). "Caloric and vestibular evoked myogenic potential tests in evaluating children with benign paroxysmal vertigo." International journal of pediatric otorhinolaryngology 71(3): 495-499.
- El-Badry, M. M., et al. (2017). "Clinical criteria of positional vertical nystagmus in vestibular migraine." Acta Otolaryngol 137(7): 720-722.
- Hamed, S. A., et al. (2012). "Assessment of cochlear and auditory pathways in patients with migraine." Am J Otolaryngol 33(4): 385-394.
- Harno, H., et al. (2003). "Subclinical vestibulocerebellar dysfunction in migraine with and without aura." Neurology 61(12): 1748-1752.
- Joffily, L., et al. (2016). "Assessment of otoacoustic emission suppression in women with migraine and phonophobia." Neurol Sci 37(5): 703-709.
- Mora, R., et al. (2009). "Electronystagmography in migraine equivalent syndrome." Otolaryngol Head Neck Surg 140(4): 566-572.
- Oh, S. Y., et al. (2009). "Gaze-evoked and rebound nystagmus in a case of migrainous vertigo." Journal of neuro-ophthalmology : the official journal of the North American Neuro-Ophthalmology Society 29(1): 26-28.
- Polensek, S. H. and R. J. Tusa (2010). "Nystagmus during attacks of vestibular migraine: an aid in diagnosis." Audiol Neurootol 15(4): 241-246.
- Salviz, M., et al. (2016). "Diagnostic value of vestibular-evoked myogenic potentials in Meniere's disease and vestibular migraine." J Vestib Res 25(5-6): 261-266.
- Thompson-Harvey, A. and A. A. Mikulec (2018). "Total caloric eye speed in patients with vestibular migraine." Am J Otolaryngol 39(2): 180-183.
- Toglia, J. U., et al. (1981). "Common migraine and vestibular function. Electronystagmographic study and pathogenesis." Ann Otol Rhinol Laryngol 90(3 Pt 1): 267-271.
- Vitkovic, J., et al. (2008). "Neuro-otological findings in patients with migraine- and nonmigraine-related dizziness." Audiol Neurootol 13(2): 113-122.
- von Brevern, M., et al. (2005). "Acute migrainous vertigo: clinical and oculographic findings." Brain : a journal of neurology 128(Pt 2): 365-374.
- Yollu, U., et al. (2017). "Vestibular migraine screening in a migraine-diagnosed patient population, and assessment of vestibulocochlear function." Clin Otolaryngol 42(2): 225-233.
June 16, 2018
, Timothy C. Hain, M.D.
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June 16, 2018