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DEAR DR. ROACH: Can you shed light on how vestibular migraines are diagnosed and the best treatment? – J.H.
ANSWER: The vestibule of the ear is where the organ of balance is located, so vestibular symptoms relate to balance issues in general, but most commonly, it means vertigo. The term “vestibular migraine” means vestibular symptoms attributed to migraine.
Vestibular migraine thus includes migraine headache – not everyone will have headache with every episode, but most people with vestibular migraine will have headache with at least some of the episodes – and vestibular symptoms. These could include vertigo (a sensation of movement when still), unsteadiness or movement symptoms with a change in head position that persists long after the head has moved. Abnormal sensitivity to sound and vision are also prominent in vestibular migraine.
There is a similarly named condition, basilar migraine, that also has vestibular symptoms. However, basilar migraine has additional symptoms seen during the early, or aura, phase coming from the brainstem, deep in the brain, such as clumsy movements or confusion. These occur most commonly five minutes to an hour before the headache.
Making the diagnosis of vestibular migraine is challenging, since there are many clinical entities with similar symptoms. There is no conclusive laboratory or radiology test to confirm the diagnosis. In practice, the diagnosis of probable vestibular migraine is made in people with recurrent migraine symptoms associated with vertigo. Often, treatment is begun when the condition is considered probable, and if the person does not respond well to treatment, a more thorough evaluation is considered.
Treatment for vestibular migraine is broken down into treatment for acute attacks and treatment to prevent attacks. Many neurologists use diazepam (Valium) and similar drugs for acute attacks. Preventive medicines come in many different families, and the choice of the best agent depends often on other conditions the person has. Everyone with migraine should try to find and avoid triggers. This includes eating on a reasonable schedule and good sleep hygiene.
If medications are needed, prescription choices include blood pressure medicines (beta blockers like propranolol and calcium channel blockers), antidepressants and seizure medicines. Over-the-counter options include riboflavin, magnesium, feverfew and coenzyme Q10, all of which have some but not conclusive evidence of benefit superior to placebo.
DEAR DR. ROACH: Can you tell me the possible causes of psoriasis? I have read that it is related to chronic inflammation. What type of inflammation might this be? – C.K.
ANSWER: Psoriasis, a chronic skin condition that can sometimes affect the joints, is indeed an inflammatory condition, but inflammation is a set of symptoms and observable signs, not an underlying cause or diagnosis. There are five cardinal signs of inflammation: redness, swelling, pain, warmth and loss of function.
Psoriasis appears to be a problem of a dysregulated immune system. It is unclear what triggers the body to begin responding with inflammation to the skin, but some proteins (called antimicrobial peptides) made by skin cells may start the process. These can be triggered by trauma to the skin, but also by some medications, alcohol, cigarette smoking, infections and stress, all of which also can act as triggers for people with psoriasis. These make the immune system cells specific to the skin become much more active.
Understanding the immune system issues in psoriasis has led to newer and more effective treatments, especially for more-severe psoriasis.
Dr. Roach regrets he is unable to answer individual letters, but he will incorporate them in the column whenever possible. Readers may email questions to ToYourGoodHealth@med.cornell.edu.
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