Migraine may represent a risk factor for benign paroxysmal positional vertigo and could explain why some cases of vertigo occur in younger patients.

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Benign paroxysmal positional vertigo (BPPV) ranks as one of the most frequent causes of dizziness and vertigo, with an approximate lifetime prevalence of 2.4%. BPPV occurs most often among people in their fifth or sixth decade of life and is more common in women. Although BPPV is benign in nature, it can still bring about debilitating episodes that restrict daily living. Those with BPPV report higher levels of anxiety and depression and have negative life events more often.

Studies have also shown that BPPV is associated with higher risk for ischemic stroke, diabetes, osteoporosis, and migraine. “Traditionally, we’ve thought of various ear diseases—such as BPPV, Meniere’s disease, or vestibular hypofunction—as separate diseases,” explains Jeffrey D. Sharon, MD. “However, over the last 10 to 20 years, we’ve become increasingly aware that a history of migraine puts people at risk for all these diseases. A history of migraine may also change clinical aspects of those diseases, but we don’t fully understand why this occurs.”

Increasing Understanding of the Migraine-BPPV Relationship

Dr. Sharon and colleagues conducted a retrospective study, published in Cureus, that examined the relationship between migraine and BPPV more formally. “We wanted to see how often patients with BPPV had a history of migraine and determine whether age at diagnosis was different in those with and without migraine,” Dr. Sharon says. “We also wanted to determine if migraine was associated with higher rates of falls or other problems.”

For the study, investigators analyzed how migraine may predict the onset, severity, and recurrence of BPPV and dizziness-associated falls. The primary outcomes included age at BPPV onset, the Dizziness Handicap Index (DHI), BPPV recurrence, and dizziness-related falls. The total cohort included 255 patients (mean age, 63), most of whom (89.0%) had posterior canal BPPV (PC-BPPV). A much smaller percentage (11.0%) had horizontal canal BPPV (HC-BPPV).

History of Migraine Common in BPPV

The researchers found that 44.7% of all patients with BPPV in the cohort had a history of migraine (Table). “This finding was surprising, because the estimated prevalence of migraine in the general public is only about 10% to 15%,” says Dr. Sharon.

Participants with and without migraine had similar DHI scores regarding dizziness and recurrence rates, as well as comparable fall rates overall.

“Another key finding was that patients with a history of migraine presented earlier in life with BPPV than those without migraine,” Dr. Sharon says. “It’s already well-known that age is a risk factor for BPPV, but it seems that migraine is also a risk factor for BPPV. This may explain some cases that occur in younger patients.”

In a subgroup analysis, migraine rates did not differ between the PC-BPPV and HC-BPPV groups (44.9% vs 42.9%). However, in the HC-BPPV group, 50.0% of patients with migraine experienced falls, a rate significantly higher than the 6.3% of patients who did not have migraine and experienced falls.

Screen for Migraine After BPPV is Diagnosed

“Considering that migraine is very common in people with BPPV, clinicians should screen people who are diagnosed with BPPV for migraine,” says Dr. Sharon. “Our study also suggests it is possible that the mechanism of migraine somehow affects the inner ear. Our belief is that BPPV occurs when crystals break free from the utricle. After they break free, the crystals float through inner ear tunnels, eventually settling at the bottom of the posterior canal. The loose crystals in the posterior canal cause vertigo in people with BPPV by tricking the rotation sensor in the posterior canal when the head is turned a certain way. Our study suggests that migraine may somehow cause the crystals to dislodge from the utricle.”

There is still “much to learn,” Dr. Sharon says. “Future research should explore if specific types of migraine—such as migraine with or without aura—are associated with BPPV, if migraine severity is clinically significant in BPPV, and if migraine treatment can help prevent BPPV from occurring.”