S4 E3: Vestibular Migraine 2

A National Migraine Centre Heads Up Podcast transcript

Vestibular Migraine 2

Series 4, episode 3

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[00:00:00] Did you know vestibular migraine is the commonest cause of vertigo in adults, but is very often unrecognised and underdiagnosed. Dizziness with migraine attacks is very common, but much can be done to be helpful and to ease the symptoms.


[00:00:21] Welcome to the Heads Up podcast brought to you by the National Migraine Centre, the only UK charity treating Migraine and headache.


Dr. Katy Munro [00:00:30] Welcome to this episode of the podcast. It is my great pleasure to be speaking today to Dr. Shin Beh, who is a neurologist who’s got a special interest in vestibular migraine. So we’re going to be talking all about vestibular migraine, what it is and what you can do about it. So welcome and thank you very much for coming on the podcast today. So tell us a bit more about yourself, Shin.


Dr. Shin Beh [00:00:56] Sure. So, you know, I’m a neurologist, as you said. I am currently in Dallas, Texas, and, you know, met with the snow melting, thank goodness. My speciality is otoneurology. Some people call it neuro-otology. There’s a lot of, you know, back and forth as to what are we supposed to be called? You know, Dizzy Doctor is fine.


Dr. Katy Munro [00:01:17] Yes, I noticed that’s your social media handle, isn’t it?


Dr. Shin Beh [00:01:22] Makes it easy. Everyone understands it.


Dr. Katy Munro [00:01:25] So you’ve been interested in vestibular migraine in particular. What sparked your interest? Was it just something you kept coming across or did you have a sort of signature patient that triggered your interest in it?


Dr. Shin Beh [00:01:40] It was somewhat by accident. So, you know, I had some interest in vertigo and dizziness. And, you know, after my training, I started seeing patients with vertigo and dizziness and very quickly noticed that the vast majority of my patients had vestibular migraine. Listening to patients stories, most of my patients had been to like multiple different doctors, no answers, no treatments and so, you know, got me more focussed on vestibular migraine as an entity. And then, you know, I began to find out, oh, actually, you know, it’s a very treatable condition. You know, a lot of people get better from it. But, you know, there’s such a lack of understanding about the condition out there. And so I decided to focus more on that and look into it further, study it a little bit more and, you know, try to help as many people as we can.


Dr. Katy Munro [00:02:31] Yeah, I think my experience as a headache specialist at the National Migraine Centre is that it is a common thing, but there’s a bit of confusion amongst my colleagues as well as patients as to how you define somebody as having vestibular migraine rather than migraine with dizziness as part of that. So some people have a bit of both, don’t they?


Dr. Shin Beh [00:02:52] So, absolutely. So, you know, a lot of people with migraine have issues with dizziness. It’s part of you know, and you’re very familiar with this, it’s the hot migraine brain. You know, very sensitive to visual stimuli, very sensitive to anything that, you know- if there’s a disagreement between the sensory input so, if there’s any visual or vestibular mismatch, then, of course, most migraine patients are sensitive to that, which is why a lot of people with migraine have motion sickness and, you know, they cannot tolerate like 3-D movies, you know, certain video games. It makes them very uncomfortable. It’s part of the hot migraine brain and it’s not uncommon for people with migraine also to experience some form of dizziness during the migraine attacks or in between the migraine attacks. Vestibular migraine, you know, of course, if you have migraine and dizziness, that does not automatically mean you vestibular migraine. Vestibular migraine is a subset of migraine where the attacks are characterised by vertigo and dizziness. Headache may not play such a prominent role in it, but, you know, the predominant and the most disabling symptom would be vertigo. I think ICHD-3 and Barany Society, they have come up with the criteria for it. And so, you should have a history of migraine or a current diagnosis of migraine. You have to have at least five episodes of vestibular symptoms. They have to last between 5 minutes to 72 hours and at least half of them have to come with at least one migraine feature, either the light and sound sensitivity, the typical headache, or, you know, the visual aura. So that’s kind of how we tease out those who have vestibular migraine versus, you know, migraine with dizziness. But there’s a lot in between. There are a lot of people who have, you know, dizziness and say a little light sensitivity may not have sound sensitivity some have the headache, some may not have the headache, some have just these episodes of dizziness and vertigo with the typical migraine triggers like weather changes, caffeine, lack of sleep, not eating on time, but they don’t have any other migraine features. So, you know, there’s a lot in the in-between part too.


Dr. Katy Munro [00:05:04] Yeah. And I think it can change throughout life as well as, can’t it? Although I see some children. I saw a couple of kids the other day who had a lot of vestibular symptoms without in the way of headache. But we also see women going through the perimenopause and the menopause sometimes their headache diminish, but the dizziness factor kind of comes to be more predominant. Is that your experience, too?


Dr. Shin Beh [00:05:26] Absolutely. So, you know, I think it reflects the hormonal changes through life. So like children, that you mentioned, there are children who have, what we call, benign recurrent vertigo. It’s the childhood form of migraine. And then, you know, as they go through puberty, that goes away and then the headache part comes in and we see more, you know, girls compared to boys after puberty getting migraines, you know, migraine headaches predominantly. And as you approach the menopausal period, you know, the headaches tend to fall off and then vertigo and dizziness tends to come back again. Yup, absolutely.


Dr. Katy Munro [00:05:58] So sometimes it’s a little confusing to know whether we would call this an aura or whether it’s not migraine with aura and as I understand it, it’s the length of time the dizziness goes on for that makes us not classify it as an aura, is that right?


Dr. Shin Beh [00:06:13] Absolutely. So the definition of the aura, like you’ve mentioned, has to be 5 minutes to 60 minutes. It has to precede or start at the beginning of the headache phase. You know, not all the vertigo and dizziness symptoms fall in that strict category of aura. So not many people- you can’t really classify it as an aura in the vast majority of people.


Dr. Katy Munro [00:06:35] Yeah, that’s what I thought. And that has implications, obviously, if we’re deciding on which oral contraceptives in young women and things, whether they’ve got an aura type of migraine or not. So you mentioned the sort of linked symptoms in childhood and motion sickness is a really common one, isn’t it? And benign paroxysmal vertigo in children. What else would children have that might make us kind of think all this is a more vestibular type of migraine? Are there any other features, or are there any specific features in adults or is it all the same that people would get with other migraine?


Dr. Shin Beh [00:07:11] There are a lot of childhood variants of migraine, you know, colic is one that we are recognising now. There’s no research into if you develop colic as a child, would you go on to develop a vestibular migraine later on? But the link between colic and migraine is very well known. Now there is the abdominal migraine that is cyclic vomiting as well. So those it could be argued that, especially cyclic vomiting, that may be very closely related to vestibular migraine. You know, there’s a lot of nausea, vomiting with it but not much research. I think that’s an area that really needs to be looked at further. There are certain childhood variants of migraine that could go on to predict who will develop vestibular migraine later on in life. Motion sickness, you know, not very specific, but, with migraine, definitely there’s a big link there. I’m not aware of any research that would tease out if you have motion sickness, you know, do you have a higher likelihood of getting vestibular migraine or migraine? We need to know more about that for sure.


Dr. Katy Munro [00:08:22] We need more research in almost every aspect of migraine treatment, I think, don’t we? We need to keep raising awareness, raising the flag! Let’s look at more on migraine. So, the other thing about vestibular migraine is, of course, there’s loads of other things that can make people dizzy that aren’t vestibular migraine. So I just really wanted to kind of talk about some of those and what, you know, people sometimes get misdiagnosed or they go down one diagnostic pathway and then realise later that they’ve got vestibular migraine. Meniere’s is the one that comes up quite often. There’s quite a link, isn’t there?


Dr. Shin Beh [00:08:57] Absolutely. So Meniere’s disease is the big one that, you know, everyone gets diagnosed with initially and there’s a huge overlap with migraine. Half of Meniere’s disease patients have migraine and half of the time a Meniere’s disease attack can be followed by a migraine attack. So with Meniere’s disease, especially with vestibular migraine, there can be a lot of confusion. And I’ve been surprised many times myself where, you know, I swear that the patient has Meniere’s disease, but then because all the treatments for Meniere’s disease have not worked and the patient doesn’t want to go for surgery. You know, we say, ‘hey, let’s try migraine treatment. Let’s see whether it works’ and it works much to everyones surprise. The rule of thumb that I usually follow would be, Meniere’s disease symptoms are very asymmetric. So the ear pressure, the ringing, the roaring, tinnitus, the loss of hearing is usually, you know, one sided, whereas with migraine typically the symptoms are in both ears because, you know, it’s coming from the brain, not from the ear itself. There are a small number of vestibular migraine patients who describe, you know, strictly unilateral symptoms. They always say, ‘it’s only on one side’. Some of the patients actually, you know, it follows the side of the headache. So, they have a right sided headache then the ear pressure and ringing is on the right side. If it’s on the left, it’s on the left. If I see evidence of low frequency hearing loss on the audiogram over time, then that favours more of Meniere’s disease compared to the vestibular migraine. Patients who are diagnosed with Meniere’s disease and then let’s say they see me years later, over five years or six years you don’t see any hearing changes at all. No hearing loss. Hearing still remains good. You know, in those people, it’s very unlikely to be Meniere’s disease. The symptoms, of course, if the attack comes with light sensitivity, sound sensitivity, the headache, the visual aura, of course, that would favour vestibular migraine. But like we talked about earlier, you know, a Meniere’s disease episode can be followed by a migraine attack. So that makes it very confusing. The duration of the attack of vertigo can also be a little bit useful. You know, in the Meniere’s disease definition, it should last between 20 minutes to 12 hours. Now, that falls within the time limit for vestibular migraine as well. But, you know, in patients who experience vertigo episodes that go more than, let’s say, 24 hours or 48 hours, 72 hours, then that makes it much less likely to be Meniere’s disease and more likely to be vestibular migraine.


Dr. Katy Munro [00:11:44] That’s really helpful because I think that’s often a diagnostic thing, but the deafness and hearing loss in Meniere’s is usually progressive, as I understand it. It can be progressive whereas do you get hearing loss in vestibular migraine?


Dr. Shin Beh [00:12:00] Studies that have come out, they show that some degree of mild bilateral high frequency hearing loss can occur in people who have vestibular migraine, but the low frequency asymmetric type of hearing loss is more characteristic of Meniere’s disease.


Dr. Katy Munro [00:12:17] So those audiograms give us a really big clue.


Dr. Shin Beh [00:12:21] Absolutely. If a person comes with vertigo and hearing symptoms, ear symptoms, you know, we definitely should get the audiogram.


Dr. Katy Munro [00:12:27] Need to get them sent off for that. Excellent. So a relative of mine other day, who hasn’t got migraine, was suddenly struck down with acute vertigo and vomiting and it lasted about 24 hours. So me being a migraine specialist was thinking, ‘oh, has she suddenly got migraine?’ But of course, she got better quite quickly. So I’m guessing that that would have been more likely to be a vestibular neuritis or labyrinthitis kind of viral infection, possibly?


Dr. Shin Beh [00:12:54] Single episodes can be very hard to determine. Whether it’s- is it the first episode of vestibular migraine? Is it vestibular neuritis? Could it be something else, God forbid, a stroke or TIA? It’s tough to tease out in the beginning. You know, of course, if it came with the light sensitivity, the sound sensitivity, the headache, then, of course, you know, that would favour vestibular migraine. Vestibular neuritis, you usually get, you know, about a day to about three days, sometimes up to about a week of vertigo. They have usually preceded by some upper respiratory type of symptoms, sometimes pain behind the ear. And during the VNG or caloric testing, you would see that, you know, one side was weaker than the other and that would favour, of course, vestibular neuritis. Sometimes time can tell as to what it would turn out to be.


Dr. Katy Munro [00:13:48] Yeah.


Dr. Shin Beh [00:13:48] So you know if you have just one single episode, you know, and then that’s it, it’s highly unlikely to be migraine. Still could be migraine. Some people get, you know, a few migraine attacks throughout their life and that’s pretty much it. If it’s a recurrent issue, however, if you’re getting like an episode of vertigo every month, let’s say, then vestibular neuritis is highly unlikely. Dr. Kattah, he came up with the HINTS exam [Head Impulse Nystagmus-Test of Skew], you know, the head impulse test, looking at nystagmus, looking at skew deviation. So if a patient comes to you with a first episode of vertigo lasting hours, two days, and then you examine them and if the exam points to a central pathology, then of course, you would suspect a stroke and you should work them up for a stroke. Any patient who comes in with the first attack of vertigo ever in their life, you know, lasting for hours like what you described, I think deserves an MRI just to make sure we’re not dealing with any other major problems. Most of the time, thankfully, it will come back unremarkable, it’s part of the workup that should be pursued.


Dr. Katy Munro [00:14:53] So somebody suggested to her that she might have benign paroxysmal positional vertigo, but she had really intense vomiting throughout the first 24 hours. So, usually you don’t get nausea or vomiting with benign positional vertigo, do you?


Dr. Shin Beh [00:15:08] You could in more sensitive people. Again, it comes down to how sensitive a person is, like, you know, like my dad had BPPV before and, you know, he’s got the migraine brain so he tends to be more sensitive to stuff like that and he got really bad nausea and vomiting with it. The vast majority of my patients don’t get the nausea and vomiting with BPPV. The other thing to remember about BPPV is also it’s positional. So, you know, if you keep completely still, you shouldn’t be spinning. The spinning would happen if you tilted your head in a specific way, turn in bed, you know, lean a specific way, then it would give you little quick bursts of vertigo. You could feel really bad, disoriented, dizzy for the rest of the time. But, you know, if you are constantly just spinning and spinning and spinning, even if you don’t move your head around, then that makes it more likely to be BPPV.


Dr. Katy Munro [00:16:01] A few years ago now, I learned how to do an Epley manoeuvre and of course doing that in the GP surgery when you’ve diagnosed somebody with BPPV, you can very quickly improve things with that. So that was a real joy to be able to offer patients that, you know, within 10 minutes we could have done something positive to help them. But of course, tipping them onto the couch and turning their head this way and that doesn’t make any difference to vestibular migraine, probably actually makes it feel worse.


Dr. Shin Beh [00:16:30] You can make them feel a little worse, you know, some of the vestibular migraine patients also have positional vertigo. So they’re the interesting part. They can be a little bit confusing with BPPV, especially if that’s the only type of vertigo that they experienced during the vestibular migraine attack.


Dr. Katy Munro [00:16:45] The other thing people worry about is whether they’ve got MS. Does MS commonly cause dizziness?


Dr. Shin Beh [00:16:51] So dizziness is a very general term. Right? A lot of things can make you dizzy. So if you look at MS, you know, MS can affect the cerebellum, can affect the brain stem, can affect the spinal cord and so it is not uncommon for MS to manifest with ataxia. A lot of patients also have proprioceptive loss because of the location of the spinal cord lesions. And so what happens is they find that they’re really unsteady, especially in the dark. A lot of them feel just really unsteady on uneven ground. And so it’s important to take history from the MS patients and, of course, to examine them. Right? You know, if you find that the patient describes sensory ataxia type of symptoms, you know, more loss of balance in darkness, with uneven ground. And then when you examine them, there’s reduced vibration and joint position sense that would point towards sensory ataxia. You do the workup, you see the characteristic lesions and the diagnosis of MS can be made. Similarly, if they have cerebellar ataxia, then you examine them, you see the heel-shin ataxia, all the D’s, right? The dysmetria, the dysdiadokinesia, the intention tremor and all of that, that would favour, you know, MS and then you do a workup. In some rare situations you could get vertigo from an MS plaque if the MS plaque is strategically located. So you know, if it hits the root entry zone on the 8th nerve or hits the vestibular nuclei in the brainstem, then definitely you could get vertigo from the MS plaque. Usually, if it were to cause vertigo, you know, it kind of presents like the vestibular neuritis type of picture. A few days to about a week of intense vertigo and then, you know, it settles down. But after that, because there is demyelinating plaque there at times, you know, patients can get these little bursts of vertigo that come every time there’s a little short circuit within the plaque, they get a burst of vertigo from it.


Dr. Katy Munro [00:18:57] But if you did a neurological examination on somebody who had just plain, ordinary vestibular migraine- that’s not probably the right term but, you know what I mean- the diagnosis was just one of vestibular migraine. A neurological examination on them would be likely to be completely normal, is that right?


Dr. Shin Beh [00:19:15] Yes. Usually. You could see some eye movement abnormalities, but the rest of the exam should be normal.


Dr. Katy Munro [00:19:22] It’s tricky to examine people when we are working remotely at the moment in lockdown in the UK.


Dr. Shin Beh [00:19:26] Very difficult.


Dr. Katy Munro [00:19:28] We have to be even more scrupulous about our history taking. Yeah, that’s one of the problems of the COVID pandemic. So there’s a couple of other diagnostic confusion things that I wanted to particularly ask you about, and one is PPPD. So I always forget what it stands for. Persistent Postural Perceptive Disorder, is that right?


Dr. Shin Beh [00:19:52] Persistent Postural Perceptual Dizziness. Tongue twister.


Dr. Katy Munro [00:19:55] That’s it. So PPPD can be present as well as vestibular migraine, but it is a separate thing. And I’m getting quite confused about what is the difference?


Dr. Shin Beh [00:20:09] So PPPD or triplePD, I think it rolls off the tongue better. Right? So triplePD is, if you think about it, it is kind of similar to post-traumatic stress disorder in a way. It’s not the same thing, but, you know, if something makes you really dizzy, gives you really bad vertigo or some really bad form of stress occurs or you’re really sick, the brain can be left in this state of just dizziness for a very long time. You know, like with post-traumatic stress disorder, some trauma occurs and then the person is left with the anxiety, the panic, nightmares, flashbacks, all related to that trauma. And the dizziness can last for a very long time. So, you know, if you think about it, any condition that causes vertigo can lead to triplePD. Vestibular neuritis, BPPV, vestibular migraine. The issue with vestibular migraine too, is that, the hot migraine brain is very sensitive to a lot of things that also characterise triplePD like, you know, head movements make them really dizzy, certain visual stimuli make them really dizzy as well. And so, there’s a huge overlap between the two entities. You definitely could have vestibular migraine and triplePD at the same time. A lot of my patients with vestibular migraine do. How about, you know, just triplePD versus vestibular migraine? I think it’s a little easier to tell the difference between the two. So, you know, I have patients who have triplePD who were diagnosed with vestibular migraine. So triplePD, you typically have this constant, almost persistent type of dizziness. They feel kind of off, disoriented, discombobulated, some people feel as if the environment is moving around them a bit, aggravated by visual stimuli. It last for months, you know, the diagnostic criteria says three months at least. And if it’s just this constant dizziness without, you know, much variation, you don’t have these big attacks where they get really dizzy with the migraine features then that favours more triplePD rather than vestibular migraine. Now vestibular migraine, and if you have both conditions, then I would expect to see these big attacks, you know, vestibular migraine attacks where they are even more dizzy, coming with the migraine features or triggered by the usual migraine triggers that you expect to see.


Dr. Katy Munro [00:22:37] Right. Oh, that’s really helpful. Yeah. Because I think, you know, that’s something that a lot of patients haven’t come across before. But we certainly do see people who are getting that sort of constant not quite study in the world feeling. And the other thing I was going to ask you about was Chiari 1 malformation. So a lot of the patients that I see will have had brain scans and some of them come and they say, ‘well, I’ve been told that I’ve got Chiari 1 malformation’ and I know that some of the findings are incidental and not the cause of the dizziness. And yet sometimes people get subjected to further investigations or neurosurgery even just because they’ve identified that. So can you explain a bit more about what Chiari 1 malformation is and what we should be doing about it?


Dr. Shin Beh [00:23:31] Absolutely. So the Chiari 1 is when you’re born with the back part of your skull being a little too small, right? So, you know, there’s not much space there already. And so if you’re born with an extra tight space, what happens is part of the cerebellum is squished downwards into the foramen magnum, that’s the opening of the skull to your spine. And usually symptomatic cases would result in pressure related symptoms. So people with symptomatic Chiaris, anything that increases the pressure in the head like bearing down, straining when you’re defaecating, when you’re blowing your nose, sneezing, sometimes coughing, lifting something heavy. You know, what happens is the pressure in the head goes up and that squishes the cerebellum even more. And that typically results in, you know, vertigo attacks, loss of stability, headaches. So if a patient has headaches and vertigo that are provoked by straining or Valsalva manoeuvres, then that is more likely a symptomatic Chiari. There are a lot of people who have asymptomatic Chiari’s, where although it appears, you know, squished in the back, there still appears to be enough room that when they perform those manoeuvres, they strain, they cough, they sneeze, it doesn’t squish it enough to cause those symptoms. You’re absolutely right. I think it’s very important to try and tease out which are the symptomatic Chiari’s versus asymptomatic Chiari’s. That’s why history is very important. If you have an asymptomatic Chiari and then you have vertigo episodes that are more consistent with vestibular migraines, you want to treat vestibular migraine, you don’t want to put a person at risk of brain surgery, opening the back of the skull, creating more space, it’s something you want to avoid. It is one of those areas where you have to take the history and not just rely on the MRI. You just look at the MRI and you’re like, ‘oh, it’s a Chiari’, but you know, the history is very important to decide whether it’s asymptomatic Chiari or an asymptomatic Chiari.


Dr. Katy Munro [00:25:45] Yeah. I think that’s good guidance and will be helpful in reassuring patients. And if you’re treating them for vestibular migraine, you’re doing something much less invasive than doing something which involves brain surgery. So they’ll probably be quite pleased to try those treatments first. We haven’t come to the end of all the different things that can be mistaken. But I wanted to move on a little bit to other common conditions that occur with people with vestibular migraine or any type of migraine, and that’s mental health issues like anxiety and depression. So I had a 14 year old with me the other day who had been quite commonly told that this was because he was very anxious, but actually he seemed to be quite sensible and he was getting very significant attacks of dizziness and completely well in between. It’s really common, isn’t it, anxiety and depression?


Dr. Shin Beh [00:26:44] Absolutely. So mood disorders like, you know, anxiety and depression, very, very common in people with migraine and even more common in people who have vestibular migraines. I think Dr. Tedji in Italy did a study where, you know, you went into the psychiatric wards and interviewed patients and people with anxiety actually have a higher incidence of dizziness and vertigo as well. And so, you know, it’s a two way street. You know, people who have migraine and vestibular migraine have a higher incidence of anxiety and depression, and people who have anxiety and depression have a higher incidence of migraine and vestibular migraine. And so, you know, it’s very, very common in people who have vestibular migraine especially with triplePD. In triplePD, there’s this huge overlap with anxiety type of symptoms. But I think to blame it all on anxiety or depression, I think it’s very dangerous. Number one is, you know, you’re telling the patient that it’s purely a mood disorder. And number two, you’re missing a chance to treat the conditions. That being said, recognising the presence of anxiety and depression is very important because if you’re just focusing on migraine treatment and not addressing the mood disorders, you could be missing out as well on treating holistically. You know, a lot of times the improvement in the mood also will help improve the migraine symptoms too. So, you know, you need to address both conditions.


Dr. Katy Munro [00:28:10] Yeah. And I was reading your book. I thoroughly enjoyed reading your book. And one of the things you mentioned in there is about acceptance of the diagnosis. And I think, you know, certainly one of the things that I’m trying to do along the journey with patients is to enable them to live their lives with their migraine and not put their lives on hold while their migraine takes over. So acceptance is about that, I guess?


Dr. Shin Beh [00:28:37] It is. So, you know, it is accepting that it is an incurable condition. Migraine and vestibular migraine, there’s no cure. Accepting it will give you that opportunity to say, ‘okay, you know, I have migraine, I have vestibular migraine. I have certain triggers. I can’t eat chocolate, I can’t drink red wine’. And so, you know, you can go on, you can just accept it. ‘I need to be on certain treatments for migraine, I need to do certain things. I can’t stay up too late. I can’t sleep in too late’. You know, that allows you to get everything under control. It’s like with blood pressure or diabetes. So, you know, once you accept that, ‘okay, I have hypertension. I can’t go out and eat a whole bag of chips covered in salt’ or, you know, with diabetes, ‘I can’t eat a whole cake anymore’. You need that to be able to manage your health better.


Dr. Katy Munro [00:29:28] And acceptance doesn’t mean giving up. Does it? It’s about finding the way to live with it and keeping hold of hope and looking for strategies that you can incorporate into your life. I wanted to talk about some of the treatments, so some of the things that you mentioned in your chapter about nutraceuticals I was very familiar with. So we often recommend magnesium and we recommend riboflavin or vitamin B2 and coenzyme Q10 and probiotics. That’s a kind of common thing that we’re advising. But there were quite a number of other things that you meantion. So vitamin D, I’m a fan. I’m a big fan of vitamin D, I’ve been mentioning it to my patients for ages, especially living in the very cloudy, rather sun deprived UK.


Dr. Shin Beh [00:30:16] Definitely. So, you know, there’s more evidence that vitamin D and migraines are really related, you know, low vitamin D levels are found in people who have migraine and supplementation with vitamin D has been shown to improve it. Vitamin D is a very interesting, you know, not really a supplement, it’s kind of like a hormone in your system actually. It also is very interesting, you know, inflammation is part of migraine. That whole migraine attack, there’s this neuroinflammation that goes on. Vitamin D seems to control inflammation to an extent. You know, it can control help with depression as well. So, you know, both migraine and depression, there’s this is huge link, vitamin D can play a role in that, too. So, you know, vitamin D is really, really safe. If I remember correctly, there were some studies from the eighties that showed, you know, normal, healthy people could take 20,000 units a day. No problem whatsoever. I think the only people that should be a bit cautious would be people with renal failure and hypoparathyroidism. It’s good to be cautious there and have the endocrinologists manage their vitamin D more. But i think for everyone else vitamin D supplementation is fine.


Dr. Katy Munro [00:31:24] I think the recommendation over here is for every adult to be taking 800 to 1000 international units every day through the winter from October till April. But that’s quite a small dose. That will just keep your vitamin D level where it is, won’t it? It doesn’t kind of get it back up if it’s dropped down. So yeah, it’s quite a hot topic over here.


Dr. Shin Beh [00:31:43] For most people, I tell them them to take 5000 a day. I take 5000 a day myself too, I think that should be, you know, pretty safe.


Dr. Katy Munro [00:31:49] And of course, the darker your skin, the more sunshine you need to make the vitamin D when the sun does come out, doesn’t it? When we do get through to some sunny weather, we need to go out and get it for free.


Dr. Shin Beh [00:31:59] Then you have to worry about skin cancer.


Dr. Katy Munro [00:32:00] Yes, true. Go cautiously. There are lots of good advice websites about vitamin D. And the other thing you mentioned, which was new to me, was about melatonin being present in tart cherry juice. So we talk to patients about melatonin and we did one of our podcast episodes on Sleep and mentioned the role of melatonin. But I didn’t realise by drinking some tart cherry juice you could get some naturally occuring melatonin.


Dr. Shin Beh [00:32:26] Absolutely. You can get it in tart cherry juice. The main thing is to make sure you don’t get the ones with too much sugar in them.


Dr. Katy Munro [00:32:34] Rotting your teeth while you’re getting a good night’s sleep and getting rid of your migraine or putting on weight. Melatonin is important for anybody with migraine and particularly in vestibular migraine or just the same as any kind of migraine?


Dr. Shin Beh [00:32:45] It’s not been studied in vestibular migraine specifically. A lot of the supplements and the treatments that we use, you know, come from the migraine world. You know, you just say, ‘hey, this works on migraine, it could work for vestibular migraines’. You take that, you apply it. Definitely melatonin can help quite a bit. Number one, it helps with sleep for sure, right? You know, sleep irregularity is very common in people with migraine and it can help with that. Itself can help with migraine, exactly how I don’t think we are very sure just yet but it appears to help. One of the things is, you know, they said could it be acting on the hypothalamus or another one is, you know, it’s pretty similar to indomethacin in chemical structure so there may be some influence from that standpoint, too. So, you know, more research.


Dr. Katy Munro [00:33:36] We need more research, definitely. More research. Scented oils? So that’s something I hadn’t come across and I would have instinctively sort of said to patients, ‘well, if you’ve got a hot migraine brain, then scented oils might aggravate you’. But I guess that’s probably just an individual thing, is it? Some people don’t have the osmophobia, the smell aversion and so tell me, I think you mentioned peppermint, lavender, rose, even eucalyptus.


Dr. Shin Beh [00:34:06] So there have been studies that show that smelling those during a migraine attack can abort a migraine attack or, you know, relieve the symptoms or using it for motion sickness or nausea can also improve the symptoms. Again, like you said, there are people with migraine who have sensitivity to odours. A lot of people do but not everyone has them. And during the attack, some people have increased sensitivity to smell, some people don’t. So the key is to try and find out what affects you and what doesn’t. If you talk about- like peppermint oil is the one that, you know, seems to be used quite a bit or anything with menthol in it, Vicks, for example, you could even use that. One of the things is that could it be interrupting the trigeminal transmission, you know, because menthol is a pretty pungent odour. You know, it won’t just stimulate your olfactory system, I’m sure there will be some trigeminal stimulation as well and so, that may be influencing it from that standpoint. You know the rest like Rose and all that or lavender, you know, there could be some calming effect, some anxiety relieving effects on there but could it also be affecting the trigeminal system, that’s a possibility there. But the ones most people with migraine- the smells that they’re more sensitive to are like artificial, you know, fragrance type of things like air fresheners, for example, detergents, lotions, those perfumes. Those are the ones that seem to cause more offence to people with a migraine. You know, I wonder if more quote unquote ‘natural type of smells’ like peppermint, lavender and all that may be better tolerated.


Dr. Katy Munro [00:35:51] Better tolerated, Yeah. Because diesel is quite commonly an irritant to people. Or kind of strong cooking smells as well. Well that’s really interesting. Omega three and oily fish. So it’s all about the ratios, isn’t it? Omega three and omega six. Do you recommend a supplement that people try? A supplement of omega three?


Dr. Shin Beh [00:36:16] The supplements, unfortunately- it’s again not been studied in migraine. The supplements, the efficacy of the supplements, you know, taking from the cardiovascular world there’s been so many different studies and conflicting results as to the supplements, whether they do help or they don’t help. One of the possibilities is that the supplements, they don’t really contain as much omega three as they’re supposed to. Degradation from extracting it from the fish and everything could be a problem there. And so, you know, it seems that people who have a diet that’s higher in omega three tend to do better, compared to just taking supplements. So I think the oily fish definitely would be useful. You know, seeds could do it, too. The flaxseeds, the chia seeds contain a lot of omega three so that’s another thing if you’re concerned about, say, the cost of oily fish or, you know, if you’re worried about the mercury content of the oily fish. Again, you get the omega three, but you get a good dose of mercury, no fun there.


Dr. Katy Munro [00:37:18] Yeah, but nuts and seeds are quite good. I often recommend those to patients for snacking on as well, obviously, if they’re not allergic to nuts. You always have to be cautious when you recommend things to people and say, ‘just make this fit into your life and your preferences’. But yeah, nuts and seeds are generally a healthy food.


Dr. Shin Beh [00:37:35] But the nuts could trigger migraine.


Dr. Katy Munro [00:37:37] I know. I don’t think we can go into diet today because there’s so many conflicting things. I think we need to do a whole episode on diet and what’s the evidence? And I often say to people, you know, basically don’t let your blood sugar drop down to too low and and try to eat lower carbohydrates generally, because that seems to be- complex carbs, slow release energy foods, loads of vegetables. And I’ve been kind of reading around about diet and it is adviced to have a lot of fermented foods for the health of your gut microbiome but then of course fermented foods can also be a trigger.


Dr. Shin Beh [00:38:17] Fermented foods are good from one end, but you know, for migraine sufferers, unfortunately, the tyramine, histamine content of the fermented foods can trigger migraines. So again, but, you know, it’s not for everyone. So, some people are more sensitive to it than others. So the key is to test it out. If you find that your migraine attacks are provoked by, say, you know, kombucha, kimchi, all those things, then, of course you have to avoid them. But if you can consume those and those don’t trigger your migraines, why not? Go ahead.


Dr. Katy Munro [00:38:50] Go ahead. Yeah, I think that’s the thing. It’s, basically, trial and error, isn’t it? If you eat something and every single time you eat it, you get a migraine attack shortly afterwards, it’s probably best not to keep eating it is generally the advice. But I do have a lot of patients who go through and do sort of wide exclusion diets and put themselves through all sorts of, you know, avoiding this and that and the other. And I guess it’s just getting some good advice on making sure that you’re doing that in a healthy way.


Dr. Shin Beh [00:39:24] Elimination diet will be okay to start off with. If you’re having really bad issues, you know, you want to clean everything out and then what you could do is slowly reintroduce stuff back in, I guess because there’s a lot of healthy foods out there that, you know, could potentially trigger migraines and that’s nuts, you talked about. So almonds are very healthy, full of magnesium, which could be good for migraine. Right? They don’t trigger attacks in every single person. And so if you could eat almonds, have nuts, or say, avocados, citrus, you know, if they don’t cause migraine attacks for you there’s no point depriving yourself of them. But the key would be to test it out, to reintroduce them to your diet slowly, see if they, you know, cause any migraine attacks or not.


Dr. Katy Munro [00:40:07] I think the other thing is that with migrainey brains, you have to be patient and you have to realise that things are going to change slowly. There’s no quick fix, there’s no magic wand.


Dr. Shin Beh [00:40:17] Even in the latest migraine treatments like you’ve talked about, the CGRP inhibitors, you know, Aimovig, Ajovy, Emgality. They take, for the full benefit to be realised, you need about six months to a year. So you know, you got to be patient with them.


Dr. Katy Munro [00:40:34] I wanted to ask you a bit about exercise because in your book there’s a really helpful kind of step by step instructions for how people can exercise to help quieten down their vestibular systems. And in the last episode we did on vestibular migraine, I was actually talking to a vestibular physiotherapist who was really helpful in the way she was describing. So as I understand it, it’s best not to do anything in the way of vestibular exercises while your brain is actively and acutely in a flare up.


Dr. Shin Beh [00:41:05] Absolutely right. So in general if there are a lot of attacks going on, if you’re having let’s say an attack almost every day, you know, the brain just cannot tolerate anything whatsoever. Even the slightest movement of your head makes you dizzy. Then those exercises, it’s probably a good idea to avoid them. In the beginning, get on the right medication, get on the right treatment. Once things start to calm down, we’ll see. I would often re-evaluate and see if the person still has a lot of issues, let’s say, with balance, if they have trouble, you know, with certain visual stimuli, although the vestibular migraine attacks have calmed down quite a bit, in those situations, that’s when I would refer a person for vestibular therapy to try to get the brain desensitised or accustomed to those type of stimuli.


Dr. Katy Munro [00:41:53] So the worst thing is to stop moving and stiffening up and walking around in a kind of rigid posture, trying to avoid feeling dizzy can actually make things worse because you end up with a kind of poor posture in your neck and shoulders.


Dr. Shin Beh [00:42:07] Neck and shoulder problems. And then neck and shoulder pain. Very closely linked to migraine pains as well. So if you get neck problems, that would occur with your migraine. So, yeah, definitely.


Dr. Katy Munro [00:42:18] Yeah. An exercise generally is a good thing for people with migraine, isn’t it? But we were talking in a different podcast episode about the fact that sometimes if people do a lot of intense work on their neck and shoulders, like weightlifting or swimming, doing breaststroke and sticking their heads up so they’re hyperflexing or hyperextending their necks, then that can trigger off a migraine attack. So it’s about finding, again, the right kind of exercise for you that doesn’t interrupt or aggravate things. I had a patient the other day who said her vestibular migraine was really helped by massage therapy. Deep tissue massage therapy and that can be quite useful, can’t it?


Dr. Shin Beh [00:43:00] Absolutely. You know, it goes into all the neck pain, the shoulder pain. If you’re having a lot of issues with those types of pain then your migraines tend to be worse in general. They think there’s a link, too, with like back pain, fibromyalgia. If there’s more pain coming from the rest of your body, you know, your brain is just more sensitive to pain, more sensitive to migraine attacks. So, you know, controlling pain as a whole, you know, whichever source it comes from, I think would also help with the migraine.


Dr. Katy Munro [00:43:27] So the more pain messages that your brain is receiving, the more it’s interpreting almost any message as pain. Yup. And the wind up of the brain occurs and then we’re kind of on the knife edge then all the time, as to going into an attack or not.


Dr. Shin Beh [00:43:44] You become hypersensitised to pain all the time. You know, I think that’s where exercise is very useful. Many things you get from exercise, you get the endorphins from it, you strengthen weaker muscles, your posture gets better, cardiovascular health gets better, depression gets better so exercise is the single best thing for depression, actually.


Dr. Katy Munro [00:44:04] And especially if you can go outdoors and do something out in the fresh air, in the daylight, which probably not so advisable if your knee deep in snow as you are in Texas at the moment.


Dr. Shin Beh [00:44:13] Or with COVID running around, it’s not too good.


Dr. Katy Munro [00:44:16] Yes. There’s a new trend of bare chested running or something, which I was seeing an article about on the news the other day. I’m not planning that myself. Cold water swimming is also quite a trendy thing to do over here. It does seem to be helpful for some people just plunging into the very icy water. Yeah, that’s a whole other story.


Dr. Shin Beh [00:44:40] It can help your migraines, like the whole thing about the ice cream headache stopping a migraine attack.


Dr. Katy Munro [00:44:46] Yes, that’s true. So going on to how we can manage an attack. So we’ve talked a little bit, we touched on the lifestyle things which are basically the same for vestibular migraine as they are for migraine with headache, aren’t they? I mean keeping regular diet, regular sleep. There’s just a question about histamine. So we are seeing an increasing number of patients, which when we ask them specifically, do you get allergies, do you get asthma, do you have gastric indigestion or IBS? Are you hypermobile? The answers come back yes, yes, yes, yes, yes. And we’ve become increasingly aware of mast cell activation syndrome and hypermobility syndromes. Are they more likely to get vestibular migraine or is it just common for those patients to have more migraine in general?


Dr. Shin Beh [00:45:41] They tend to have more migraine in general. Now, they could have more vestibular migraine. The issue also is, you know, we don’t have the research on that just yet as to whether vestibular migraines specifically compared to migraine is more prevalent in these populations. But migraine for sure. You know, definitely a lot of people with hypermobility syndromes have higher migraine incidents. People who have, you know, a lot of the gut stuff like you describe, you know, irritable bowel syndrome, gluten sensitivity, a lot of them do tend to have more issues with migraine. Could it be some autonomic thing going on like you say with Pott’s, for example? So people with Pott’s tend to have more issues with migraine. Could it be histamine? Now, I’ve read some interesting research into diamine oxidase, DAO.  A deficiency in DAO seems to cause a lot of gut issues like you know gluten sensitivity, urticaria, eczema, asthma, itching, runny nose, all the allergy type of things. And I believe it was a study from Spain that showed that the DAO activity was lower and some people who have migraines but you know, supplementation did show that, it did help a little bit with the duration of the migraine attacks, but didn’t really show much of the improvement. So histamine, you know, definitely plays a big role.


Dr. Katy Munro [00:47:09] Yeah, I had read that study as well. And I think they’ve looked into it in Spain but not many other places have looked at histamine. But we’ve been talking to patients about their symptoms and you know, an antihistamine is a very straightforward easy thing to try. And if it helps them generally feel better, even if it doesn’t specifically help their migraine, if it stops some of the sort of mast cell histamine-y type reactions that are making them feel uncomfortable or unwell then that’s a positive step forward and something very straightforward to do. Very interesting topic.


Dr. Shin Beh [00:47:47] Cyproheptadine. That one has some antihistaminic properties too and guess what? Helps a lot with migraines, especially in children.


Dr. Katy Munro [00:47:54] We hardly ever use that in the UK. I asked my UK headache specialist group the other day about cyproheptadine because I had read a lot of studies from the States that talk about it and said, ‘why aren’t we using this over here?’ They kind of shrugged their shoulders and said, ‘Well, I don’t think it’s licensed’. So it’s not widely used in the U.K. which is interesing.


Dr. Shin Beh [00:48:16] Is it not licensed in the U.K.?


Dr. Katy Munro [00:48:18] I don’t know whether it’s not licensed or- I think it’s not licensed yeah.


Dr. Shin Beh [00:48:24] Oh. Interesting.


Dr. Katy Munro [00:48:25] Interesting. So we read all these options in the U.S. papers and then going, oh, we haven’t got that here. Maybe it will come in as more understanding of histamine related things.


Dr. Shin Beh [00:48:39] It’s an old medication.


Dr. Katy Munro [00:48:39] Yeah. It’s very safe too, isn’t it?


Dr. Shin Beh [00:48:41] Yeah. It’s like domperidone. We don’t have that here.


Dr. Katy Munro [00:48:48] Ah. We still have domperidone, but only just. So pizotifen, that has a mild antihistaminic effect. Am I right?


Dr. Shin Beh [00:48:58] I think so, yes. Like the calcium channel blocker: Flunarizine.


Dr. Katy Munro [00:49:05] Yes. Also difficult to get here and difficult in the States, I think.


Dr. Shin Beh [00:49:10] It’s not available here. No, Flunarizine is not available here.


Dr. Katy Munro [00:49:13] No. So it’s very dependent on where you are in the world as to what therapies are available to your doctors let alone to you. So just talking a bit more about preventative medications, one of the things that, again, I hadn’t come across when I was reading your book was timolol beta blocker eyedrops as a preventer, but also as a rescue therapy. So tell me a bit more about those.


Dr. Shin Beh [00:49:42] So there was some interesting study. I forget the person who published it, but it was a small study that showed, you know, in migraine sufferers that timolol eyedrops actually help them abort the attacks. I used it more of like- I started using it when I saw a lot of my patients who had sensitivity to other medications, sensitive to every single medication that we tried. So, you know, out of desperation.


Dr. Katy Munro [00:50:06] Yeah.


Dr. Shin Beh [00:50:07] Let’s try this one and see if it works. And with people who are women who are pregnant, you know, also, you are limited in the number of medications that you can use. So we began trying it out. I found it surprisingly did help quite a bit. And so, we used it for prevention and used it for rescue. It doesn’t help everyone, of course, nothing helps everyone.


Dr. Katy Munro [00:50:29] Nothing helps everyone.


Dr. Shin Beh [00:50:31] Anyone that promises 100% of patients, it helps. You get a little suspicious there, right?


Dr. Katy Munro [00:50:36] Yes.


Dr. Shin Beh [00:50:38] It’s like venous stenting for MS, they claim 100% of patients it helped. It didn’t really help. But, you know, the timolol eyedrops it can help some patients and it’s pretty well tolerated in general. I did have a few- I’ve seen a few patients in whom they actually noticed that they had a drop in their blood pressure, a little bit of drop in heart rate when they used it and so back off then.


Dr. Katy Munro [00:51:03] Okay.


Dr. Shin Beh [00:51:04] But most people they tolerate it quite well.


Dr. Katy Munro [00:51:07] So is it a set dose and you just put one drop in each eye or?


Dr. Shin Beh [00:51:11] Yeah, I typically go with 0.5%. You put one drop in each eye twice a day for prevention. And then when you have an attack you put an extra drop in each eye. You know, an interesting point was I think an ophthalmologist suggested it because I had a few patients who said they couldn’t stand the burning in the eye. So the ophthalmologist told them to put under your tongue and it worked. So, alright, put it under your tongue.


Dr. Katy Munro [00:51:36] You heard it here first, folks. So that’s really interesting. So you would usually avoid any kind of beta blockers, though, in anybody with the history of asthma, even if it was eye drops, I presume?


Dr. Shin Beh [00:51:50] I think the eye drops would be quite safe unless they have really bad asthma. You know, if it’s like really well-controlled I don’t really take that as a big contraindication. I think you would know better. You’re more familiar with the beta blocker and asthma. I use it if the patient has like really well-controlled asthma and it doesn’t give them problems. They just use a rescue inhaler from time to time. You know, if it’s more severe, then, of course, probably not a good idea.


Dr. Katy Munro [00:52:19] We tend to be a bit cautious with the beta blockers and asthma. And certainly my colleagues in the National Migraine Centre are like, ‘Oh, no, no, no, let’s not risk it’. So they may feel the same way about that, but not enough information, I think, is the answer, isn’t it? Again. The other drug that you mention which I haven’t used personally for migraine patients or for VM is lamotrigine. So is that something that you find- would you use that as a first line, or would you kind of use that as maybe second, third, if the standard things like amitriptyline, the tricyclic antidepressants or the beta blockers haven’t helped?


Dr. Shin Beh [00:53:02] So I don’t really follow like a first line, second line, third line kind of approach. I try to make it, you know, choose one that’s suitable for the patient. So lamotrigine, I use it quite a bit. You know, there was one small study that showed that it did help with the vertigo attacks, but not the headache. I’ve seen that it helps quite a few of my patients with vestibular migraine. Typically I would use lamotrigine in people who say, you know, like if they have bipolar disorder, they are already on some low dose of lamotrigine and they have, you know, vestibular migraine. I say, ‘hey, you know, let’s ramp up the dosage. Let’s see if that helps’. I use it quite a bit in people who have mood disorders as well. So depression especially, you know, lamotrigine has some effects on depression, especially if they have a history of being really sensitive to conventional antidepressants. I use it also in people who have a history of, you know, like saying that they don’t want to go near the tricyclics, they have had trouble with that in the past. Or if they’ve tried like a number of medications like, you know, topiramate and all the rest. And the only thing that they have not tried would be lamotrigine. I tailor the approach to the patients. You do have also patients who prefer not to start any of the other medications, you know, they read like really bad things about topiramate or tricyclic antidepressants and then they don’t want to do the beta blockers and so you’re left with lamotrigine or some of the other medications. It depends on who you are seeing, the patient that you’re seeing. There’s, I believe, some evidence that gabapentin and lamotrigine, they have some synergistic effects in people who have epilepsy. And so, you know, let’s just say if a person has been on gabapentin and not doing so well but the Gabapentin helps to an extent, cannot tolerate higher doses because of the sedation. Then you could try adding a little bit of lamotrigine to see whether, you know, the combination of the two could help.


Dr. Katy Munro [00:55:13] Uh huh. Okay. That’s really interesting. And then you mentioned the antiCGRP drugs. So these are the new kids on the block and we’ve got them over here. We had finally had them approved on the NHS, but of course, the pandemic has slowed everything down, so people are not finding that it’s easy to get hold of them. So I think you had a good year ahead of us over in the States. Are you finding that those are helpful for the vestibular part of the vestibular migraine or are they more beneficial for people who have more severe headaches?


Dr. Shin Beh [00:55:48] We think that it does help with the vestibular migraine as well. So I do have a number of patients who use the CGRP antibodies. The interesting part, also, is that I’ve found that some of my patients also do well with the gepants, you know? So yeah, rimegepant, ubrogepant, they do find that, you know, not all of course but I have a group of patients that say it breaks the attacks quite well.


Dr. Katy Munro [00:56:17]  So we’re talking about acute treatments and we normally advise that the triptans are very good for headache. And so if you attack it’s mainly vertigo, then it may not be worth taking a triptan, but reading your book you were saying, well, actually it might be, it does help some people to having either a triptan or a gepant.


Dr. Shin Beh [00:56:36] Yeah. So they do help. A lot of my patients, they find that the triptans do help which I find very interesting. The more interesting part is that I initially started off thinking the NSAIDs won’t help at all with the vertigo attacks. But, you know, some of my patients actually find that the NSAIDs also help. I’m like, yeah, okay, take the NSAID.


Dr. Katy Munro [00:56:58] So it’s worth a try with ibuprofen or naproxen or aspirin. Can aspirin help?


Dr. Shin Beh [00:57:03] Aspirin could potentially help. But you know, aspirin could also cause tinnitus. So if you have a bit of tinnitus already you may not want to use the aspirin for them.


Dr. Katy Munro [00:57:12] Maybe keep away from that one. Yes that’s true. And then the nausea and vomiting, of course, can be quite troublesome. And I understand that prochlorperazine can be really helpful in vestibular migraine particularly. What sort of dose would you use for that?


Dr. Shin Beh [00:57:30] I think in migraines too that could potentially help. I think we usually go with about 10 milligrams.


Dr. Katy Munro [00:57:36] Yeah, it’s about the same over here. 5 or 10 milligrams. And sometimes you can get those sort of- the ones you tuck into your cheek. The buccastem they’re marketed as over here. Which means you don’t have to swallow something, which is quite helpful because if people are feeling really sick. And do you use metoclopramide much?


Dr. Shin Beh [00:57:58] Not as much in general. I think we should probably be using it more, but not very much in general. I think one of the issues is, you know, you always worry about the akathisia, the movement disorders that can come with them. Generally, most of my patients because they would prefer to sleep after, you know, if they get a one of their migraine attacks or vestibular migraine attacks. I use quite a bit of promethazine.


Dr. Katy Munro [00:58:22] Okay. Yeah. That’s a bit sedating generally. So sedating your vestibular attack, but also sedating you so you can go and have a little snooze.


Dr. Shin Beh [00:58:32] And you have the suppository form of that. I think also, if I’m not wrong, they have the gel form now.


Dr. Katy Munro [00:58:40] Oh, that’s worth knowing. I know that almost everybody in the headache world would say opiates are no, no and butalbital it’s something again that we don’t come across here very often. But we’re constantly saying to people, ‘please don’t take codeine, please don’t take opiates, please keep away, keep away’. And it’s the same for people with vestibular migraine isn’t it? It’s just a bad idea to have anything that’s opiate related.


Dr. Shin Beh [00:59:08] Absolutely. I stay away from the butalbital you know, unless somebody has been started on butelbital and uses it say once a month at the most or twice a month maybe. I’m okay with that, you know, but I never use opioids.


Dr. Katy Munro [00:59:20] I tend to have a bit of a face that I pull when people say ‘I’ve been taking the codeine’. I have to be careful about that.


Dr. Shin Beh [00:59:30] I give them all kinds of warnings about the opioid.


Dr. Katy Munro [00:59:34] The other thing, which has, over the last couple of decades, been rather frowned on doctors prescribing them is the benzodiazepines. So as a GP and there’s a lot of pressure to not ever use benzodiazepines, but your book was suggesting that they’re quite useful in vestibular migraine attacks. So how would you use those? Just purely as an acute treatment?


Dr. Shin Beh [00:59:59] There are two ways you could use it. So, number one is you could definitely use it as an acute treatment. So, let’s say if a person has- it depends on the length of the attacks too. If my patients have attacks that last, let’s say a day, two days, then medications like clonazepam would probably be more useful. If the attacks last about a half a day to about a day, diazepam would probably be the more helpful one. Lorazepam could be used as well. You could also use it to break, let’s say, cluster. So I use it if, let’s say, my patients with these weather changes, for example, and they’re having like back to back migraine attacks, I give them a course of, say, lorazepam or clonazepam at bedtime for about two weeks. Knock everything down and then come off.


Dr. Katy Munro [01:00:50] Yeah.


Dr. Shin Beh [01:00:53] They could also be useful in people who have, let’s say, they fail all the medications. If every single thing you’ve tried doesn’t work or they cannot tolerate them, the only thing that gives them some relief is a bit of clonazepam at bedtime. I think that’s reasonable to use. You talked about triplePD earlier, of course, first line of treatment medication-wise for triplePD would be the antidepressants. If those don’t work and let’s say, they cannot tolerate the antidepressants or they fail and the only thing that you’re left with would be, you know, the benzos. I guess you would have to use them. Again, earlier we mentioned that, you know, first line, second line, third line and I said, I don’t have any. To revise that statement a little bit. So, I keep benzos as a last resort if we need to.


Dr. Katy Munro [01:01:45] As a last resort.


Dr. Shin Beh [01:01:47] If we really need to use them, then, we use them. But again, you have to weigh the risks and benefits of everything. Right? The risks of benzos and then, you know, the benefits would be helping the patients get some quality of life back and if everything else has failed and that’s the only thing that can help, we have to go for it.


Dr. Katy Munro [01:02:08] And of course, you have to have the conversation with the patient about the warnings about addiction and drowsiness and hangover sort of the next day if you’re driving or heavy machinery, all of those kind of things, which we’re constantly doing. So, yes, I agree. I think if it would be something it would be very low down on the list of headache specialists over here, but maybe something just to have at the back of our minds. Excellent. And is there anything else that you think I should have asked you about and that you’d like to share about vestibular migraine? Anything you’d like to say just as a summary?


Dr. Shin Beh [01:02:45] I think the interesting thing that we didn’t cover would be neuromodulation.


Dr. Katy Munro [01:02:51] Oh, yes, yes.


Dr. Shin Beh [01:02:53] I think that one is showing some promise. The vagus nerve stimulator, the gamma core, and then you have the Cefaly device. Those I think will be very interesting areas. And so I’ve used it so far with the migraine rescue. They seem to work quite well, the Cefaly seems to helping with migraine prevention too and so, I think those would be very, very interesting areas to investigate. They are very safe, no side effect issues and no addiction issues. If they could be used in the future, I would say, you know, that definitely, yeah. That’s something that we need more research into.


Dr. Katy Munro [01:03:32] Yeah, they’re very interesting. The Cefaly dual is the one that’s available most easily over here because you can buy it. It costs about- it’s quite expensive. It costs about £336 at the moment, but there’s a money back guarantee. So if you’ve had it for two months, you can get some of your money back if you don’t like it. But the other one I know is coming soon, hopefully over here, but you’ve already got it in the States is the Nerivio, which you put on your arm, don’t you? Which seems a bit counterintuitive. You imagine you’re going to have to stick something on your head, but putting something on your upper arm that sends electrical impulses into your brain can help.


Dr. Shin Beh [01:04:12] They think it’s mostly from the distraction of the pain. If there’s another source of pain, then, you know, the brain is focussed on the other sources of pain. So, you know, since you don’t have it there yet, just maybe have somebody punch you really hard in your arm. You focus on the pain, then you forget about the pain in your head. No, I’ve not tried the Nerivio on my patients with vestibular migraines just yet. The one that I’m looking forward to, which could be quite interesting, is, I forget which company is studying it, but there’s a device that they are looking into where it stimulates the trigeminal and occipital nerve.


Dr. Katy Munro [01:04:55] I haven’t heard about that one.


Dr. Shin Beh [01:04:55] That could be a very interesting one to try out.


Dr. Katy Munro [01:04:58] Because we were able to get, in some places, we were able to get the sTMS spring device, the magnetic thing, but that’s of course not available at the moment, is it?


Dr. Shin Beh [01:05:08] They went back.


Dr. Katy Munro [01:05:10] They’ve had issues. Yeah. Big issues. Yeah. Such a shame because some people found that useful.


Dr. Shin Beh [01:05:17] Honestly, they priced themselves too high. It was too expensive. We couldn’t prescribe it to patients because, you know, so expensive. Insurance wouldn’t pay for it. I think the good thing about the manufacturer that makes Cefaly is that they priced- it’s expensive, but it’s not insanely expensive, right? It’s still okay, you know, you can still purchase it, but it’s not like, you know, completely bonkers.


Dr. Katy Munro [01:05:43] Yeah, I agree with you. I think that having something to try, which is not involving swallowing yet another tablet and doesn’t have side effects. You know people are very happy to explore those options. The Botox injections and greater occipital nerve blocks of course we didn’t mention either and those could be useful presumably as well for people with vestibular migraine.


Dr. Shin Beh [01:06:03] Absolutely. So, you know, I’m finding- because Botox can be a little bit tough to get approval for and it’s a bit expensive so, you know, if a patient has like pure vertigo attacks as part of the vestibular migraine, it’s much tougher to get approval for the Botox. Patients who have headache and vertigo attacks it’s easier to get approval for that here. I find it’s a mixed picture. So, you know, I have some patients in whom it helps their vertigo attacks as well. I have some patients who say it helps their headaches, but not their vertigo. So, definitely worth a try. Now, the occipital nerve blocks and all that, those help more with the headache part of things. I think what would be interesting to see is, let’s just say if a person has a lot of neck problems, cervicalgia, if you do like a trigger point injection to see whether that also could help with their  vestibular migraine frequency.


Dr. Katy Munro [01:06:59] There’s no magical answer for brain fog, is there? The brain fog I know is a really bothersome symptom for a lot of patients. But, sometimes quieting down the migraine attacks in whatever way they are showing themselves, the brain fog begins to clear as well. We’ve seen a number of patients who have done very well on the antiCGRP drugs, who’ve lost the headaches or they’ve felt that their migraine attacks have been much more manageable and also the brain fog has lifted and there’s such great joy when they come back to clinic and report that, ‘Oh, I can think straight now.’


Dr. Shin Beh [01:07:34] Absolutely. I think as the migraine- from what I’ve seen so far, as the migraine symptoms improve, the brain fog also tends to lift.


Dr. Katy Munro [01:07:43] So in summary, we need more research. We need more always.


Dr. Shin Beh [01:07:48] A lot more.


Dr. Katy Munro [01:07:48] And more awareness about vestibular migraine in particular so that people aren’t misdiagnosing any of those things we were talking about earlier on.


Dr. Shin Beh [01:07:56] Absolutely.


Dr. Katy Munro [01:07:58] Lovely. Well, thank you so much, Shin. It’s been a real delight talking to you and it’s a really interesting topic. Thank you so much.


Dr. Shin Beh [01:08:06] Pleasure. Thank you for having me.


[01:08:09] You’ve been listening to the Heads Up podcast. If you want more information or have any comments, email us on info@NationalMigraineCentre.org.uk. Till next time.

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This transcript is based on a past episode of the Heads Up podcast and reflects information available at the time of broadcast – some facts may have changed or new treatments become available since.

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