Bhatia S., Sharma D., Gupta V., Nanda M. S.
Himachal Pradesh, India
Inrtoduction
Vertigo or dizziness is the most common medical complaint to the medical professionals. It presents frequently as the most perplexing diagnostic problem. Migraine is a functional disorder characterized by recurrent headaches that are moderate to severe. Typically, the headaches affects one half of the head, are pulsating in nature, and last from two to 72 hours.
Associated symptoms may include nausea, vomiting, and sensitivity to light, sound, or smell. The relationship between migraine and vertigo has recently gained interest of many neurotologists and practitioners. There are different studies which confirmed this relationship [1]. It is reported that 30-50% of subjects with migraine complained of vertigo or dizziness [2, 3]. Migraine related vertigo is the second most common cause of recurrent vertigo after BPPV with the considerable impact on the daily life activities and wellbeing of the patient.
The Presenting Features of migraine-associated vertigo are quite varied and may include episodic true vertigo, positional vertigo, constant imbalance, movement-associated dysequilibrium, and/or lightheadedness. Symptoms can occur before the onset of headache, during a headache, or, as is most common, during a headache-free interval. Consequently, many patients who experience migraines have vertigo or dizziness as the main symptom rather than headache.
There is no specific treatment of MRV so management generally follows the recom-mended treatment of migraine headaches, and includes dietary and lifestyle modifications and medical treatment with β blockers, calcium channel blockers, and tricyclic amines.
Studies have revealed decreased levels of the micronutrients like riboflavin, magne-sium and Q10 in plasma of migraine patients. A deficit of these nutrients could play a role in the pathophysiology of migraine. Magnesium is needed in various physiological processes which influence the pathophysiology of migraine (vasoconstriction, platelet inhibition, secretion of serotonin) [4]. Magnesium is also needed as a co-factor for proper functioning of the ATP-syntheses which produces ATP. Mitochondrial dysfunction is associated with migraine [5]. Here we present three cases of MRV who reported to the ENT OPD.
Case 1
A 48 year old male presented in ENT OPD with complaints of unilateral headache off and on for past few years. Headache persisted for few hours but off lately he was c/o rotatory vertigo persisting for few minutes during attack of headache. Headache occurred 1-2 times per week .History of nausea and sweating was positive. Patient c/o occasional photophobia.
There was no history of any aural fullness, tinnitus, phonophobia or subjective loss of hearing. No h/o any trauma or intake of any drugs. No h/o diabetes mellitus or hypertension. He was advised routine and oto- neurological investigations like CBC, ESR, CRP, Lipid profile, thyroid function test and vitamin D levels. Audiological investigations included PTA, Acoustic reflexes, special tests, ABR and VEMP. All the tests and investigation were normal except the Vitamin D levels which were very low.
Patient was started on Magnesium Glycine complex and Vitamin D3 for 8 weeks. Patient was reviewed initially after 4 weeks where the patients had only 2 episodes in a months’ time. There was substantial reduction in attacks of vertigo when reviewed after 8 weeks.
Case 2
A 36 year old female presented in ENT OPD suffering from migraine with photophobia for past 6 -8 years. Patient reported the first attack 8 years back where her migraine was related to periodic cycles, now for past one year patient is also complaining of vertigo along with the headache which occurred during or after the headache, and this vertigo persisted for 15-30 minutes and once or twice for an hour. Family history of migraine was positive. She was not receiving any treatment of migraine at the time of evaluation.
All the tests conducted on the patients were normal except the Vitamin D levels which were profoundly low. Patient was started on Magnesium Glycine complex and Vitamin D3 for 8 weeks. Patient was reviewed initially after 4 weeks, the frequency of attack had not reduced but there was decrease in the intensity of the headache. This patient certainly showed reduction in frequency of MRV after 12 weeks of treatment.
Case 3
63 year old female patient presented in OPD with long history of migraine but recently had complaints of rotatory vertigo persisting for few minutes during attack of migraine. This patient also reported photophobia and phonophobia but no loss of hearing. The patient was a known case of GERD and was on PPI for past 9- 10 years. Patient was already on drugs for migraine but was not getting any relief for past 1 year.
The oto-neurological investigations and audiological investigations were normal except Vitamin D levels which was borderline low. Patient was started on Magnesium Glycine complex and Vitamin D3 for 8 weeks. Patient was reviewed initially after 4 weeks where she did show significant improvement in reduction of attacks of migraine but complaints of vertigo. She was advised to continue the medication for another 4 weeks.
Discussion
Migraine is a neurological condition and third most prevalent illness in the world, researchers are still trying to discover how and why tit occur. Vestibular migraine is also quite prevalent but under diagnosed and the impact on daily life activities and wellbeing is considerable (6). Treatment is not well established and therapeutic recommendation is based on migraine guidelines. The need for specific treatment is urgent in order to avoid compromise on day to day life (7).
Researchers in Cincinnati hospital recently published their findings showing link between migraine and vitamin deficiencies and found alarming 16-51% of participants in their study had below average levels of vitamins [8]. Studies on Vitamin D deficiencies are limited and inconsistent.
In the presented study it was noticed that all the three cases had severe to profound Vitamin D deficiency. Recent studies show an association between low levels of vitamin D with higher incidence of Migraine. In 2008, Turner et al. reported the prevalence of vitamin D deficiency at 26% among 267 patients with chronic pain (including 25 patients with headache) [9].
In Norway, a multi-ethnic study with cross-sectional descriptive designs, hypovitaminosis D (levels less than 50 nmol/l) were reported among 58% of patients with musculoskeletal pain, headache and fatigue [10]. Celikbileck et al found serum vitamin D and Vitamin D receptors levels were significantly lower in patients with migraine as compared to the control group. Though, concentration of Vitamin D binding Protein levels did not differ between two groups [11].
The Accurate role of vitamin D deficiency in headache is unknown. The probable mechanisms in causing headache may include possible sensitization of second and third neurons due to continuous stimulation of sensory receptors of periosteal coverage (because of bone swelling) and also, central sensitization (because of bone swelling).
Other possible mechanisms of headache in patients with vitamin D deficiency are low serum levels of magnesium. Abnormal metabolism of magnesium is involved in the pathogenesis of tension-type headache. Magnesium deficiency in the brain, blood, erythrocyte, monocyte, and platelet has been found among patients with tension-type headaches and other types of headache. About 40-50% of patients with tension-type headache have low serum levels of magnesium [12].
In different studies, patients with tension-type headache have responded to treatment with magnesium. Vitamin D deficiency may lead to tension-type headache using decreased absorption of magnesium, because, intestinal absorption of magnesium through food is dependent on vitamin D and the deficiency of vitamin D can critically limit Mg absorption and produce Mg deficiency [13].
The importance of magnesium in pathogenesis of migraine is clearly established by a large number of clinical and experimental studies. However the precise role of various effects of low magnesium levels in the development of migraines remains to be discovered. Magnesium concentration has an effect on serotonin receptors, nitric oxide synthesis and release, NMDA receptors and a variety of other migraine related receptors and neurotrans-mitters [8] The available evidence suggests that up to 50% of patients during an acute migraine attack have lowered levels of ionized magnesium [14].
Two double-blind studies suggest that chronic oral magnesium supplementation may also reduce the frequency of migraine headache. In a paper published in 2012 researchers acknowledged the integral relationship between magnesium and multiple body processes. There is a theory that migraine sufferers may develop Magnesium Deficiency from variety of reasons including poor absorption, renal wastage, and increased excretion due to stress plus low nutritional intake [14].
In one of our cases the patient was on long term Proton pump inhibitors which can impair intestinal absorption of magnesium leading to hypomagnesiemia. Screening for chronic Magnesium deficiency is difficult because a normal serum level may still be associated with moderate to severe migraine. Till date there is no simple and accurate laboratory test to determine the total body Magnesium status in humans [15].
In all our present cases Vitamin D levels were low and as Mg levels could not be checked we treated these patients with oral supplementation of Magnesium and Vitamin D3 where elemental Magnesium was 250mg and Vitamin D3 1000IU. The dosage was 1 tablet twice daily given for 8-12 weeks and these patients were initially called up after 4 weeks for follow up, followed by at 8 and 12 weeks and assessed for frequency of headaches, vertigo and subjective evaluation of efficacy of treatment. This treatment was well tolerated by all patients except for mild gastritis complaint by patient who was already on Proton pump inhibitor.
Conclusions
In our presented cases we observed that all the cases had deficiency of Vitamin D and as Vitamin D deficiency is known to critically limit the absorption of Magnesium so we suspected Magnesium deficiency in these patients. All of our cases responded positively to vitamin D and Magnesium supplementation.
Based on these observations, it seems plausible that a substitution of these micronutrients in migraine patients might be able to prevent or reduce the intensity of migraine attacks. Migraine treatment with a nutritional supplement might be of benefit for patients with recurrent migraine who cannot tolerate chemical drugs due to side effects or contra-indications due to concomitant diseases and in whom the deficiency of the micronutrients is ascertained.
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