Reply to: “Response to: Migraine and Vertigo: A Marriage of Convenience?”

The authors of the original article “Migraine and vertigo: a marriage of convenience?” wish to thank von Brevern and colleagues for highlighting this contentious topic.1,2 In reply to their response there are a number of pertinent points that are worthy of clarification. On the whole it would be inappropriate to repeat the key points outlined in our original article but our colleagues' response has provided us with a further opportunity to support our case. Criteria for the diagnosis of Ménière's disease were first developed by the American Academy of Otolaryngologists and Head and Neck Surgeons in 1972 to clarify Ménière's disease.3 This was necessary because to all intents and purposes for much of the medical community, even the otolaryngological community, vertigo, and Ménière's disease were regarded as synonymous. Success of this initiative by the American Academy of Otolaryngologists and Head and Neck Surgeons was shown by the necessary revision of these criteria to more exactly define the disorder in 1995.4 The International Headache Society undertook a similar venture with respect to characterizing migraine as at that time, to the medical community, all headaches were often inappropriately defined either as migraine or tension headache.5 The success of these classifications allowed accurate comparison of diseases and treatments between centers and across continents. In the world of dizziness there is a schism between Europe and North America. In North America, vertigo means spinning. If there is no spinning there is no vertigo. In Europe, vertigo includes spinning but can mean a sensation of movement of self or surroundings, which is not spinning, so-called non-vertiginous vertigo. This discrepancy has been addressed by the recent Barany First Iteration of 2007, which will hopefully unify dizziness and vertigo descriptions throughout the world.6 At the same time, the Barany Society included dizziness associated with migraine as a recognized disorder. A difficulty with respect to this arises as the International Headache Society classification of migraine with vertigo and dizziness is limited, reducing the ability of physicians, neurologists, and otologists in addressing the dizziness or vertigo in migraine and the even more ubiquitous migraine without headache (to some an oxymoron) satisfactorily. The International Headache Society classification of headache is very helpful as a first step as is the new First Iteration of Dizziness. Specifically, this First Iteration by the Barany Society draws attention to the well-established fact that the cause of much dizziness is unknown and offers support for some of it being due to migraine. The authors in their response to our article make a good case for more than a fortuitous association of migraine, Ménière's disease and recurrent dizziness of unknown cause (nonspecific dizziness). These figures largely quantify their own work. Clearly, although they show an association, they do not offer overwhelming proof that most vertigo of unknown cause is due to migraine. In fact, they show that although there is a probable association, it may be small. When Fleming described penicillin he did not need a double-blind crossover trial (indeed, they did not exist) to show that it worked. The figures given by the authors of the response support their contention that this form of trial is essential as although their figures show that dizziness and migraine occur with greater than random occurrence, it is not by much. Migraine episodes are known to be triggered by many things, including foods, by relaxation after stress and in women in the premenstrual phase. It is quite likely that vestibular vertigo or vestibular dizziness is a trigger for migrainous disease and indeed this has been purported to experimentally.7 This may also explain the higher instance of migraine in Ménière's disease patients. Two actions need to happen. First, a discussion must be engaged by the International Headache Society to update their criteria. As with Ménière's disease criteria, after the First Iteration the resulting success required that the criteria needed to be optimized based on incongruities and discrepancies discovered because of the more accurate diagnosis caused by the initial classification. The International Headache Society needs, and we would recommend in collaboration with the First Iteration team of the Barany Society, to address common definitions and internationalize them so that both teams are happy with the resultant classification. The second action required is that effective clinical studies, probably multicenter drug trials, are needed to determine which dizzy (vertiginous) patients benefit from migraine medications and which do not. By doing this it may be possible to hive off patients likely to have migraine associated with vertigo as a group more likely to respond to these medications. This takes us back to the purpose of the original article which until definitions change and studies are done leaves us largely unable to answer the question of whether migraine and vertigo are definitely associated and, if so, how; are vestibular symptoms a trigger for migraine or are vestibular symptoms a part of a migraine symptom complex.

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