DIAGNOSIS: MÉNIÈRE DISEASE VERSUS VESTIBULAR MIGRAINE
The patient was given a diagnosis of Ménière disease versus vestibular migraine. Although she has a family history of Ménière disease, she does not have several of the typical characteristics of the disease, such as tinnitus and hearing loss. She had abdominal migraines as a child, which suggests that she could also be having migraines as a young adult. Unfortunately, the symptoms of these two conditions are similar, and there is no definitive test to rule out either condition.
Vestibular migraines most often begin in a person’s 20s or 30s. Symptoms include severe vertigo, nausea, vomiting, and unsteadiness. Head pain, fatigue, photophobia, and phonophobia may accompany some episodes. A family or personal history of migraine can help point to the diagnosis. Treatment options include over-the-counter anti-inflammatory medications and/or triptans. Preventive strategies may be helpful, including lifestyle modification and medical prophylaxis, such as acetazolamide, a diuretic.1
Ménière disease can present with dizziness, tinnitus, and hearing loss. Diagnosis requires the presence of recurrent vertiginous episodes, hearing loss, tinnitus, or fullness in the ear. However, these symptoms may not all be present at the onset of the disease. So, while this patient does not have ear problems, they may develop at some point in the future, potentially leading to an eventual diagnosis of Ménière disease. A hearing test and vestibular evoked potentials can be helpful in the diagnosis.
According to the International Consensus for Recommendations for Ménière’s Disease Treatment (ICON), the recommended treatments include diuretics, betahistine (which is not available in the United States), and local pressure therapy. Intratympanic injection of corticosteroids is recommended as second-line treatment, and endolymphatic sac surgery or intratympanic injection of gentamicin is recommended as third-line therapy.2 Interestingly, patients with Ménière disease have an improved quality of life when treated with medications used for vestibular migraine.3
The fact that this patient has experienced stress and sleep deprivation prior to her episodes supports a diagnosis of migraine, although these factors can precipitate symptomatic episodes in patients who have Ménière disease as well.
Migraines are treatable, while Ménière disease is more difficult to manage. This patient was given a prescription for sumatriptan. Her physician asked her to observe her response to the triptan to see if it could alleviate her symptoms when taken during an episode. She did not have further episodes for several months and did not use (or need to take) the sumatriptan. Her improvement may have been related to better sleep, lower stress, or spontaneous resolution of her condition.
• Vestibular migraine and Ménière disease are difficult to distinguish.
• Lifestyle modification can alleviate episodic symptoms, potentially prolonging a definitive diagnosis.
• Treatment of vestibular migraine can improve quality of life for patients with a diagnosis of Ménière disease.
1. Çelebisoy N, Gökçay F, Karahan C, et al. Acetazolamide in vestibular migraine prophylaxis: a retrospective study. Eur Arch Otorhinolaryngol. 2016;273:2947-2951. doi: 10.1007/s00405-015-3874-4
2. Nevoux J, Barbara M, Dornhoffer J, et al. International consensus (ICON) on treatment of Ménière's disease. Eur Ann Otorhinolaryngol Head Neck Dis. 2018;135(1S):S29-S32. doi: 10.1016/j.anorl.2017.12.006
3. Ghavami Y, Haidar YM, Moshtaghi O, et al. Evaluating quality of life in patients with Meniere’s disease treated as migraine. Ann Otol Rhinol Laryngol. 2018;127:877-887. doi: 10.1177/0003489418799107