What's in a Name? Chronic Vestibular Migraine or Persistent Postural Perceptual Dizziness?

Abstract

Current consensus diagnostic criteria for vestibular migraine (VM) describes this as an episodic disorder. However, a minority of patients report prolonged (>72 h duration) or even persistent VM symptoms, prompting whether a chronic variant of vestibular migraine (CVM) should be introduced to the current classification and how best to define it. Here we summarize current evidence of such a potential chronic variant of VM and critically review proposed definitions for CVM. Potential approaches to establish a diagnostic framework for CVM include (a) following the distinction between episodic and chronic migraine headaches, namely, frequent and/or prolonged episodes of VM (but not persistent vertigo or dizziness) in the context of chronic migraine headaches or (b) daily dizzy spells over more than 6 months that responded well to prophylactic anti-migraine therapy. A key challenge when defining diagnostic criteria for CVM is how to distinguish it from other chronic vestibular syndromes such as motion sickness, persistent postural-perceptual dizziness (PPPD), and mal de débarquement syndrome. Indeed, more than 50% of patients with PPPD and up to 46% with mal de débarquement syndrome fulfil diagnostic criteria for episodic migraine headaches, suggesting these disorders may all lie along a spectrum. We propose that when VM becomes persistent, it is best classified as PPPD but that VM and PPPD are not mutually exclusive, such that patients with PPPD need not have features of VM, and the triggering event for persistent dizziness may be independent of migraine. However, further research is needed to better characterize the spectrum of clinical phenotypes in patients with chronic dizziness, migraine headaches and anxiety, to define whether a chronic variant of VM sufficiently differs from current persistent dizziness definitions.

Keywords: chronic vestibular syndrome; dizziness; headache; mal de débarquement; migraine; somatoform; vertigo.

Figure 1

Vestibular migraine—episodic to chronic symptoms. This is a diagrammatic representation of the interplay and transition from vestibular migraine (VM), status migrainosus and persistent postural-perceptual dizziness (PPPD), proposing different paths for how chronic vestibular symptoms may arise. (A) The development of persistent postural-perceptual dizziness from recurrent episodes of vestibular migraine. (B) In patients with established PPPD, recurrent episodes of VM may occur on the background of chronic vestibular symptoms. (C) Alternatively, PPPD can arise from a single episode that impairs or threatens normal balance (e.g., VM, BPPV, or syncope). The size of the circles represents the severity of the attack in time, and the colour, its severity in functional burden (red representing maximal symptom burden). Abbreviations: BPPV, benign paroxysmal positional vertigo; PPPD, persistent postural perceptual dizziness; VM, vestibular migraine.