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 Table of Contents  
Year : 2020  |  Volume : 37  |  Issue : 3  |  Page : 110-117

Effects of vestibular rehabilitation and pharmacological therapy in patients with vestibular migraine

1 Department of Neurology, Ege University Medical School, Bornova, İzmir, Turkey
2 Department of Physical Medicine and Rehabilitation, Ege University Medical School, Bornova, İzmir, Turkey
3 Department of Otorhinolaryngology, Head and Neck Surgery, Ege University Medical School, Bornova, İzmir, Turkey
4 Department of Biostatistics and Medical Informatics, Ege University Medical School, Bornova, İzmir, Turkey

Date of Submission19-May-2019
Date of Decision04-Dec-2019
Date of Acceptance12-Apr-2020
Date of Web Publication16-Sep-2020

Correspondence Address:
Göksel Tanıgör
Department of Physical Medicine and Rehabilitation, Ege University Medical School, Bornova, İzmir 35100
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/NSN.NSN_41_20

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Objectives: The objectives of this study were to compare the results of pharmacologic management options and vestibular rehabilitation (VR) programs in the context of dizziness, balance problems, and headache in patients with vestibular migraine. Materials and Methods: Sixty patients with migraine with vestibular symptoms were evaluated in three groups in the neurology, physical medicine, and rehabilitation and otorhinolaryngology clinics of a medical school hospital. The groups were defined as routine pharmacologic therapy (PT), VR, or both. Patients were evaluated with static posturography, the Dizziness Handicap Inventory (DHI), and the Activities-Specific Balance Confidence (ABC) Scale as primary outcome measures and symptom frequency and severity (headaches and vertigo attacks) as secondary outcome measures. In-group and between-group comparisons were made using relevant statistical methods. Results: DHI scores were significantly reduced (P < 0.001) in all treatment groups. ABC scores increased significantly (P < 0.001) in patients taking PT and those on VR + PT. Posturographic examinations revealed that sway velocity values recorded on foam with eyes closed, which targets vestibular assessment, were significantly reduced (P < 0.001) in groups taking VR either alone or with PT. VR benefited patients with migraine in terms of headaches, vertigo attack frequency, intensity, and duration. Conclusion: Patients with predominant vestibular disorders can benefit from VR alone, and patients with combined symptoms (headache and vertigo) can benefit from pharmacologic and rehabilitation therapies.

Keywords: Balance disorders, exercise, headache, pharmacologic therapy, rehabilitation, vestibular migraine

How to cite this article:
Aydin &, Gökçay F, Karapolat H, Eraslan S, Bilgen C, Kirazli T, Tanıgör G, Köse T, Çelebisoy N. Effects of vestibular rehabilitation and pharmacological therapy in patients with vestibular migraine. Neurol Sci Neurophysiol 2020;37:110-7

How to cite this URL:
Aydin &, Gökçay F, Karapolat H, Eraslan S, Bilgen C, Kirazli T, Tanıgör G, Köse T, Çelebisoy N. Effects of vestibular rehabilitation and pharmacological therapy in patients with vestibular migraine. Neurol Sci Neurophysiol [serial online] 2020 [cited 2023 May 29];37:110-7. Available from: http://www.nsnjournal.org/text.asp?2020/37/3/110/295180

  Introduction Top

The association between vestibular symptoms and migraine in adults was first reported in 1984.[1] Since then, the literature has been expanding vastly. Vestibular migraine (VM) is the most common cause of spontaneous episodic vertigo.[2] The diagnostic criteria for VM were established by the International Headache Society and Barany Society and were revised in 2018.[3] The diagnosis was considered in the appendix of the new International Classification of Headache Disorders (ICHD)-3 version of the headache classification as an emerging entity needing further research.[4] It is most commonly diagnosed in middle-aged female patients. Patients usually report spontaneous or positional vertigo attacks as well as imbalance.[5] In some patients, during attacks, or in-between attacks, an examination of neural and otologic systems may not give any findings. In patients with positive findings, mild central deficits such as positional nystagmus [6] or peripheral deficits such as a decrease in unilateral caloric excitability have been reported.[7] The pathophysiology of VM has not yet been established. Observations of patients during episodes and abnormalities in interictal eye movements hint that it is a central vestibular disorder, but peripheral vestibular involvement is also possible.[8],[9] The interaction of the vestibular and sensorial pathways, beginning from the inner ear till to the cortical level, may cause vestibular symptoms and headaches.[10]

Therapeutic options in VM are usually based on migraine guidelines. Long-lasting attacks are usually treated with antivertiginous or antiemetic drugs. Specific antimigraine drugs are unlikely to be effective enough for acute attacks of vertigo. The mainstay of the management of VM is prophylactic medication. Migraine prophylaxis has been shown to be beneficial in the prevention or even abortion of acute attacks of vertigo.[11] Increasing interictal vestibulocochlear dysfunction and symptoms being persistent even between episodes highlight the importance of prophylaxis.[12]

Vestibular rehabilitation (VR) is an exercise program that uses body, head, and eye movements to stimulate the vestibular systems and restore central compensation. Exercises are graded and used to train the brain to compensate for abnormal or defective vestibular inputs, improve the role of alternative inputs such as visual or proprioceptive stimuli, develop new strategies for postural control and gaze control, increase the vertiginous threshold, and provide postural stability.[13] Therefore, VR is an important therapeutic option in patients with migraine who have consistent dizziness and imbalance exacerbated by movement.

The aim of this study was to show whether VR techniques and pharmacologic interventions were effective in the management of these patients because there is a lack of comparative data on management methods in patients with VM.

  Materials and Methods Top

The study was conducted in our facility, and power analyses showed that 17 patients were required in each group in order to show an effect size of d = 1 with a power of 0.80 and α = 0.05 (G*Power version 3.0.8 (Heinrich-Heine-Universitat, Duesseldorf, Germany)). Seventy-seven patients with a definite diagnosis of VM were initially recruited in the study. Seventeen patients were excluded from the study because they were lost to follow-up, resulting in 20 patients in each group. Patients were randomized into three groups, in the order of their admission (e.g., 1st to Group 1, 2nd to Group 2, repetitively). Informed consent was obtained from all participants, and the study was conducted with adherence to the ethical guidelines, with approval from the local ethics committee. The inclusion criteria were defined as follows: having a diagnosis of VM according to ICHD 3rd version and accepting involvement in the study. Patients with other disorders that might explain the vestibular symptoms, severe psychiatric comorbidities, a history of VR, lack of ambulation, and anatomic lesions in the middle or inner ear were excluded from the study.

The demographic data of the patients (age, sex, occupational status, and educational status) were recorded. Vertigo and headache frequency were determined by the number of attacks per month, and the severities were determined using the Visual Analog Scale, which were obtained by asking patients to indicate their levels on a 10-cm line.[14] The symptoms accompanying vertigo (tinnitus, photophobia, phonophobia, hearing loss, nausea and vomiting, and visual aura) were determined at the baseline visit. Caloric and audiometric investigations were performed to exclude other vestibular pathologies. The Activities-Specific Balance Confidence (ABC) Scale and Dizziness Handicap Inventory (DHI) were given to all patients. The validity of both forms has been shown in Turkish patients.[14],[15] Static posturographic evaluations were performed using the NeuroCom System Version 8.0.3 (NeuroCom International Inc., Clackamas, OR, USA). The mean center of gravity sway velocity (°/s) was recorded on a static platform with eyes open (EO) and closed (EC) and on foam with EO and closed (FO-EC). The patients were divided into three groups according to their order of inclusion in the study. They were treated with different therapeutic protocols. The groups were designed to receive VR, VR and Pharmacologic Therapy (PT), and PT alone. The patients were assigned to a VR program started in the Physical Medicine and Rehabilitation Department. For PT, propranolol was selected primarily and other prophylactic drugs were used in the presence of contraindications. All patients were seen at the end of the 2nd month, and the third visit was at the end of the 16th month. In these follow-ups, duration, frequency, and severity of headaches and vertigo attacks were assessed. The ABC and DHI questionnaires were completed at the end of the 16th month, alongside posturographic measurements. All patients were evaluated by the same neurologist who was experienced in this field.

Vestibular rehabilitation program

The exercises were individualized according to the symptoms and capability of each patient.

Adaptation exercises

The participants were asked to move their heads in a yaw rotation while focusing on a stationary, handheld target, called “X1 viewing,” and to progress to “X2 viewing,” in which the target and the head rotated in equal and opposite yaw directions to increase gaze stability. The exercises were performed in horizontal and vertical planes for a period of 1 min each, three times a day.[15]

Substitution and balance exercises

Substitution exercises were designed to foster the development of alternative strategies as substitutes for lost vestibular function. Other eye movement systems (saccade, central preprogramming, and slow pursuit exercise) were used to protect the participant from perceiving blurred retinal images during head movements. In these exercises, the patients were instructed to follow two different nonmoving objects with eye movements and rapidly alternate their foci from one object to another. The substitution exercises could be modified to become more difficult as the participant improved.

In balance exercises, the participant tried to restore their standing balance and proceeded to perform standing dynamic balance exercises. For standing balance, participants stood with their eyes open or closed while on a progressively narrowing base of support (feet close together, semi-tandem, tandem stance, or single-leg stance). Under these conditions, the participants were also told to turn their heads toward the right and left.

Standing dynamic balance exercises

The participants stood or moved without walking. The participants were told to do different moves such as marching in place, stepping forward or backward, stepping to the side, stepping up or down, or turning around.[15]

Habituation exercises

These exercises, which cause mild-to-moderate difficulty in daily life, were given to the participants. These exercises involved movements and positions sufficient to cause mild-to-moderate symptoms during the participant's daily activities.[15]

Ambulation exercises

The participants were instructed to walk forward (eyes open or closed), backward, sideways, along a line (narrowing the base of support), and around cones depending on their functional level. Special attention was given to how participants handled walking with head movements (e.g. voluntary head movements, on verbal command, passing balls from hand to hand, turning around). The participants were also instructed to gradually increase their walking speed and walking distance in order to enhance endurance.[15]

The hospital exercise program consisted of one session per week for a period of 8 weeks. Each session lasted approximately 30–45 min, including all exercises, and was conducted in the rehabilitation unit. All participants were followed up once a week by the physical medicine and rehabilitation specialist, who reviewed the exercises and made changes as needed in consultation with the physiotherapist.

In addition to the exercises performed at the hospital, all participants were given instructions and diagrams using software that could design customized exercises for performing a home exercise program (VHI PC kits). Home exercises were designed to take approximately 15–20 min, performed twice a day. During the training at the hospital, a physician and a physical therapist monitored compliance. The home exercises were monitored by having the participant record the sessions on a chart every day. Participants in the PT group received treatment consistent with the protocols of this study within clinical settings upon termination of their participation in the study. All participants were instructed to adhere to their therapies after the first 2 months, and their designated interventions were kept the same throughout the study. No adverse events or other major interventions that might affect the course of the study were observed or conducted in all patients.

Statistical analysis

R version 3.1.3 (R Foundation for Statistical Computing, Vienna, Austria) was used to analyze the longitudinal data. Nonparametric factorial analysis of variance was used based on the F1-LD-F1 model. Friedman's test and Dunn's test with Bonferroni adjustment were used for time comparisons in three groups because interaction was found to be significant. One-two and 1–3 differences (numbers refer to the evaluation timepoints) were calculated for comparison between the groups, and then, Kruskal–Wallis test and Dunn's test with Bonferroni adjustment were performed for the baseline values and changes in the differences. Pearson's Chi-square test was used in comparisons between the groups for categorical data. All statistical hypothesis testing was performed at the P < 0.001 significance level.

  Results Top

A total of 60 participants completed the study, and their mean age was 43.3 years; 90% of them were female. There were no significant differences in socioeconomic variables between the groups (VR, VR + PT, and PT only). The demographic features of the participants are given in [Table 1]. In all three groups, it was found that photophobia, phonophobia, and nausea and vomiting were common signs accompanying vertigo attacks, and tinnitus and hearing loss were less common. In the caloric test performed at the first visit, the rate of peripheral involvement was 15% and the rate of unilateral moderate hearing loss was detected as 3.3% on audiometry. The caloric deficits were all unilateral deficits, showing no significant differences across the groups (P = 0.69). The patients reported having headaches for about 10 years, and the duration of the vertigo symptoms was approximately 2.8 years.
Table 1: Summary of the demographic data and duration of symptoms

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Analyses of the pre- and posttreatment results of each group recorded at the 2nd and 6th months showed that VR, VR + PT, and PT alone were all significantly associated with a reduction of frequency, duration, and severity of both headache and vertigo attacks (P < 0.001) [Figure 1] and [Table 2], [Table 3], [Table 4]. DHI scores were significantly reduced (P < 0.001) in all treatment groups [Figure 1]. ABC scores increased significantly (P < 0.001) in participants taking PT and those on PT + VR [Figure 1]. Posturographic examinations revealed that sway velocity values recorded on FO-EC, which targets vestibular assessment, were significantly reduced (P < 0.001) in groups taking VR either alone or with PT [Figure 2]. Sway values of participants just on PT also trended toward reduction, but this did not reach statistical significance (P = 0.12).
Figure 1: Changes in headache and vertigo attack frequencies, Activities-Specific Balance Confidence, and Dizziness Handicap Inventory scales with time in groups. PT: Pharmacological therapy, VR: Vestibular rehabilitation

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Table 2: In-group analyses in groups taking only rehabilitation

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Table 3: In-group analyses of the groups taking pharmacologic and rehabilitative treatment

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Table 4: In-group analyses of the group taking pharmacologic treatment

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Figure 2: Changes in static posturography results for groups in time. VR: Vestibular rehabilitation, PT: Pharmacological therapy, VR + PT: Vestibular rehabilitation and Pharmacological therapy

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The comparison of the results of different treatment groups showed that vertigo attack severity and duration of participants on VR either alone or associated with PT was significantly reduced (P < 0.001) when compared with those on VR alone. Headache frequency and severity, on the other hand, was significantly reduced (P < 0.001) in participants on PT with or without VR. The between-group comparisons are shown in [Table 5] and [Table 6].
Table 5: Comparison of Activities-Specific Balance Confidence and Dizziness Handicap Inventory value differences between groups in the 1st, 2nd, and 3rd evaluations (Kruskal-Wallis test)

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Table 6: Between-group analyses in the three groups for the 1st, 2nd, and 3rd timepoints of evaluation for headache frequency and intensity, foam surface-eyes open, and Activities-Specific Balance Confidence values

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The difference of sway velocity values recorded on FO-EC of the second and third visits was significant in groups taking only PT with VR and PT (P = 0.009). The other comparisons were not significant (P > 0.05).

Loss of follow-up was attributed to personal decisions and incompliance, and no adverse events were observed.

  Discussion Top

VM is a clinical entity that requires immediate and accurate diagnosis, as vestibular symptoms affect daily activities and lower the quality of life of those affected. PT used for migraine headaches decreases vestibulopathy-related disability by reducing the severity and duration of vertigo attack frequency in patients with VM.[16],[17],[18],[19] VR can be a form of alternative treatment, particularly because of ongoing dizziness and the feeling of insecurity experienced by patients.[20],[21] VR was used for the first time in patients with peripheral vestibular pathology, and the program was improved over time and then was started to be implemented for vestibular symptoms in various vestibular pathologies. The exercises consisting of eye, head, and body movements help restructuring the vestibular system and are useful in regaining control of capacity.[22],[23]

In our study, headache and vertigo attack frequency, duration, and severity decreased significantly on follow-up in all treatment groups. The groups receiving VR showed a prominent decrease in vertigo attack severity and duration, whereas patients on PT with or without VR showed a prominent decrease in headache frequency and severity. These findings indicate the remarkable effect of VR on vestibular symptoms and PT on headaches. However, in one report, VR was reported to have contributed to improvement of headache both in patients with VM and in patients with mainly dizziness and tension-type headache (TTH). The improvement of headache is more prominent in VM compared with TTH.[24] Although patients who took only VR had an improvement of headache (P < 0.001), they still had an attack frequency of 4/month, which justifies the use of a pharmacologic agent for patients presenting with headache.

An assessment of imbalance and postural instability by Gorski et al. in patients with VM using static posturography showed that these patients had compromised balance.[25] Similarly, our patient group also showed impairments in balance. With VR, a significant decrease of the sway velocities on FO-EC was noted, which indicates an improvement of vestibular functions. This was not the case for patients on PT alone.

All patients were also evaluated with caloric tests in order to confirm that there are peripheral vestibular pathologies contributing to the present pathology. The distribution of unilateral deficits across the groups did not differ significantly. Thus, it can be inferred that the beneficial effects that differed among the groups were not due to the possible improvements of peripheral vestibular pathologies.

There are numerous studies on PT. In these studies, it was stated that various antimigraine drugs had an impact on vertigo frequency, duration, and severity in VM. Drugs acting on calcium channels such as flunarizine and cinnarizine or beta-blockers such as propranolol were found to be beneficial in the management of VM.[26],[27] In addition, topiramate, an antiepileptic, was detected to have a significant effect on headache and vertigo attacks,[28] and a diuretic, acetazolamide, was more efficient in controlling vertigo attacks.[29] In order to avoid possible differences in the efficacy of various drugs, propranolol was chosen to be the pharmacologic agent in this study.

VR is another effective method used to manage VM. The effects of rehabilitation on posturography have also been shown by Vitkovic et al. in 2013.[21] In VR studies on VM, the ABC Scale and DHI are used. Although an increase in the ABC Scale, meaning an increase in self-confidence of the individuals, is observed after VR, a decrease in the patients' dizziness-induced disability has been reported.[20],[21],[30] In our study, a significant increase in ABC scores was observed in patients receiving PT with or without VR. In the same way, statistically significant decreases in DHI scores were present in all treatment groups.

The mechanism underlying the efficacy of VR in VM could be the reduction of anxiety due to the reassurance of the physical therapist. In addition, VR encourages the patients to avoid behaviors that make them dizzy.[30],[31] We know that VM is one of the most common diagnoses in tertiary neuro-otology clinics. However, as reported by Power et al., there is poor consensus on the most appropriate initial management.[32] This study is the first to compare the efficacy of VR with PT in patients with VM.

This study is one of the first randomized controlled studies in this limited research field and has a higher number of subjects than similar studies in this field.

We chose a customized rehabilitation program approach to use in our studies, based on suggestions from previous studies.[21] Although they were uniform in intensity, types, and total duration, it was decided to have exercise interventions individualized for each patient. VR programs are usually customized for each patient in the clinical context, and nonindividualized programs may cause poor adherence in patients or may prevent them from focusing on their weaknesses. Statistically speaking, a highly predetermined but nonindividualized exercise program would reflect the impact better but would yield unrealistic results due to the problems mentioned. We tried to overcome this by fixing the exercise types, intensities, and total duration and customizing the difficulties of each exercise type for each patient.

The lack of a control group with no intervention was one of the limitations of the study. We decided that our volunteers should have at least one kind of intervention because it would be unethical to leave a patient group without any form of treatment.

While patient numbers are not lower than similar studies, having more patients would give better data and possibly more precise results. Finally, our statistical analyses were conducted per protocol, instead of a more precise design such as intention-to-treat, which could give clearer results on the benefits of these interventions.

  Conclusion Top

VR seems to be more effective on vestibular symptoms, whereas headache attacks respond to PT. Although we believe that this study will contribute to the written literature, better designed studies with a larger number of patients will be needed for the future to draw a firm conclusion on these results.

Financial support and sponsorship


Conflicts of interestb

There are no conflicts of interest.

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  [Figure 1], [Figure 2]

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]

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