Positional Nystagmus During an Attack of Vestibular Migraine

𝗢𝗿𝗶𝗴𝗶𝗻𝗮𝗹 𝗗𝗲𝘀𝗰𝗿𝗶𝗽𝘁𝗶𝗼𝗻: A 50-year-old woman presented to clinic after experiencing multiple episodes of hours-long vertigo attacks that were associated with headache, photophobia and phonophobia. She had a history of motion sickness and migraine headaches in her teenage years. She was diagnosed with vestibular migraine. She presented to the emergency department during a typical attack at which time video-oculography (VOG) recordings were performed. Video head impulse test was normal, and VOG (with removal of fixation) showed no spontaneous, gaze-evoked, or head-shaking-induced nystagmus. However, there was persistent positional (7 degree/second peak slow phase velocity) downbeat-torsional (top poles toward the right ear) nystagmus in right and left Dix-Hallpike, with milder downbeat-torsional nystagmus with straight head-hanging and prone positions. While her vertigo was continuous, head movements (including positional maneuvers) aggravated her vestibular symptoms rather than triggering them. It was felt that her positional nystagmus was ‘central' - not due to benign paroxysmal positional vertigo (BPPV) - for the following reasons: 1) nystagmus was not in the plane of a particular semicircular canal (e.g., no difference in the nystagmus vector with right versus left Dix-Hallpike), 2) there was no crescendo-decrescendo pattern to the nystagmus, 3) the nystagmus persisted for as long as the patient was kept in each position, 4) while downbeat-torsional nystagmus may represent anterior canal BPPV or apogeotropic posterior canal BPPV, her nystagmus did not behave as would be expected in either of these variants. A variety of patterns of nystagmus can be seen during vestibular migraine attacks including spontaneous horizontal, upbeat, or downbeat nystagmus, with positional nystagmus being especially common.(1) Because she was otherwise in the midst of a typical vestibular migraine attack, it was felt that her nystagmus was also migrainous. 𝗡𝗲𝘂𝗿𝗼-𝗼𝗽𝗵𝘁𝗵𝗮𝗹𝗺𝗼𝗹𝗼𝗴𝘆 𝗮𝗻𝗱 𝗡𝗲𝘂𝗿𝗼-𝗼𝘁𝗼𝗹𝗼𝗴𝘆 𝗧𝗲𝘅𝘁𝗯𝗼𝗼𝗸 𝗟𝗲𝗴𝗲𝗻𝗱: A 50-year-old woman presented to clinic after experiencing multiple episodes of hours-long vertigo attacks that were associated with headache, photophobia, and phonophobia. She had a history of motion sickness and migraine headaches in her teenage years. She was diagnosed with vestibular migraine. She presented to the emergency department during a typical attack at which time video-oculography (VOG) recordings were performed. Video head impulse test was normal, and VOG (with removal of fixation) showed no spontaneous, gaze-evoked, or head-shaking-induced nystagmus. However, there was persistent positional (7 degree/second peak slow phase velocity) downbeat-torsional (top poles toward the right ear) nystagmus in right and left Dix-Hallpike, with milder downbeat-torsional nystagmus with straight head-hanging and prone positions. While her vertigo was continuous, head movements (including positional maneuvers) aggravated her vestibular symptoms rather than triggering them. It was felt that her positional nystagmus was "central"-not due to benign paroxysmal positional vertigo (BPPV)-for the following reasons: (1) nystagmus was not in the plane of a particular semicircular canal (e.g., no difference in the nystagmus vector with right versus left Dix-Hallpike), (2) there was no crescendo-decrescendo pattern to the nystagmus, (3) the nystagmus persisted for as long as the patient was kept in each position, (4) while downbeat-torsional nystagmus may represent anterior canal BPPV or apogeotropic posterior canal BPPV, her nystagmus did not behave as would be expected in either of these variants. A variety of patterns of nystagmus can be seen during vestibular migraine attacks including spontaneous horizontal, upbeat, or downbeat nystagmus, with positional nystagmus being especially common. Because she was otherwise in the midst of a typical vestibular migraine attack, it was felt that her nystagmus was also migrainous https://collections.lib.utah.edu/ark:/87278/s6f249xk