Continuum : lifelong learning in neurology
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Continuum (Minneap Minn) · Oct 2012
Review Case ReportsSymptoms and signs of neuro-otologic disorders.
Symptoms and signs of neuro-otologic disorders are critical components in the diagnostic assessment of patients with vestibular symptoms such as vertigo, dizziness, unsteadiness, and oscillopsia. Most diagnoses can be accomplished at the bedside. An understanding of key diagnostic principles is essential for all practicing neurologists, who are often faced with determining whether such patients warrant urgent diagnostic testing or hospital admission. This article introduces readers to core concepts and recent advances in the understanding of directed history taking and physical examination in patients with vestibular symptoms or suspected neuro-otologic disorders. ⋯ A focused approach to bedside assessment of patients with vestibular symptoms is essential for accurate and efficient diagnosis. All neurologists should be aware of major recent advances.
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This article describes vestibular migraine and motion sensitivity. Migraine headache is often accompanied by dizziness or unsteadiness. A diagnosis of vestibular migraine requires that a patient meet International Headache Society criteria for migraine headache, have episodic or fluctuating symptoms highly suggestive of a balance disorder, have no recognized alternative neuro-otologic diagnosis, and experience migrainous symptoms during episodes of vertigo or imbalance. This article discusses these diagnostic criteria; the epidemiology of vestibular migraine; laboratory abnormalities in vestibular migraine; the pathophysiology of vestibular migraine; the treatment of vestibular migraine; comorbidities and overlap with other neuro-otologic disorders, including basilar artery migraine, Ménière disease, and anxiety disorders; and the genetics of vestibular migraine. This review also discusses motion sickness and motion sensitivity, including their relationship with migraine, pathophysiology, and treatment. ⋯ Vestibular migraine is becoming the preferred designation for a neuro-otologic disorder with a migrainous etiology that causes dizziness and disequilibrium. Criteria have been established for diagnosing this disorder. Although pathophysiology is as yet uncertain and randomized trials are lacking, treatment recommendations can be made. Motion sickness represents a condition often associated with migraine that can reduce quality of life.
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In 1986, the German neurologists Thomas Brandt and Marianne Dieterich described a syndrome of phobic postural vertigo (PPV) based on clinical observations of patients with nonvertiginous dizziness that could not be explained by then-known neuro-otologic disorders. Subsequent research by an American team led by Jeffrey Staab and Michael Ruckenstein confirmed the core physical symptoms of PPV, clarified its relationship to behavioral factors, and streamlined its definition, calling the syndrome chronic subjective dizziness (CSD). This article reviews the 26-year history of PPV and CSD and places it within the context of current neurologic practice. ⋯ A quarter century of research has established CSD as a common clinical entity in neurologic and otorhinolaryngologic practice. Its identification and treatment offer relief to many patients previously thought to have enigmatic and unmanageable cases of persistent dizziness. Internationally sanctioned diagnostic criteria for CSD are under development for the first edition of the International Classification of Vestibular Disorders, scheduled for publication in early 2013.
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Continuum (Minneap Minn) · Aug 2012
Review Case ReportsNonmedication, alternative, and complementary treatments for migraine.
The efficacy of some nonpharmacologic therapies appears to approach that of most drugs used for the prevention of migraine and tension-type headaches. These therapies often carry a very low risk of serious side effects and frequently are much less expensive than pharmacologic therapies. Considering this combination of efficacy, minimal side effects, and cost savings, medications should generally not be prescribed alone but rather in combination with nonpharmacologic therapies. ⋯ Therapies proven (to various degrees) to be effective for migraine include aerobic exercise; biofeedback; other forms of relaxation training; cognitive therapies; acupuncture; and supplementation with magnesium, CoQ10, riboflavin, butterbur, feverfew, and cyanocobalamin with folate and pyridoxine.
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Medication-overuse headache (MOH) is a chronic daily headache in which acute medications used at high frequency cause transformation to headache occurring 15 or more days per month for 4 or more hours per day if left untreated. MOH is a form of US Food and Drug Administration-defined chronic migraine. This review will describe (1) MOH clinical features and diagnosis, (2) pathophysiology and structural and functional MOH brain changes, and (3) prevention and treatment of MOH. ⋯ MOH development is linked to baseline frequency of headache days per month, acute medication class ingested, frequency of acute medications ingested, and other risk factors. Using less effective or nonspecific medication for severe migraine results in inadequate treatment response, with redosing and attack prolongation, frequently leading to chronification. Use of any barbiturates or opioids increases the transformation likelihood.Patients with MOH can usually be effectively treated. The first step is 100% wean, followed by establishing preventive medications such as onabotulinumtoxinA or daily prophylaxis and providing acute treatment for severe migraine 2 or fewer days per week. Slow wean or quick termination of rebound medications can be accomplished for most patients on an outpatient basis, but some more difficult problems may need referral for multidisciplinary day hospital or inpatient treatments.