Recurrent vertigo with fluctuating hearing — but it doesn't quite fit
A 38-year-old woman is referred with 4 years of recurrent vertigo. Episodes last 20 minutes to 6 hours, occur 1-2 times per month, and are often (but not always) accompanied by mild aural fullness in either ear (sometimes both). About 60% of attacks are preceded or followed by a unilateral throbbing headache with photophobia; the other 40% are headache-free. She has motion sickness susceptibility, migraine with aura since adolescence, and a family history of migraine. Audiogram during a quiet interval shows a flat 25 dB low-frequency sensorineural loss bilaterally that her previous ENT noted has not changed over 18 months.
A 38-year-old woman is referred with 4 years of recurrent vertigo. Episodes last 20 minutes to 6 hours, occur 1-2 times per month, and are often (but not always) accompanied by mild aural fullness in either ear (sometimes both). About 60% of attacks are preceded or followed by a unilateral throbbing headache with photophobia; the other 40% are headache-free. She has motion sickness susceptibility, migraine with aura since adolescence, and a family history of migraine. Audiogram during a quiet interval shows a flat 25 dB low-frequency sensorineural loss bilaterally that her previous ENT noted has not changed over 18 months.
Which Bárány criterion makes vestibular migraine MORE likely than Ménière's disease here?
She is examined 2 weeks after her last attack. Cranial nerves intact. No spontaneous nystagmus with or without fixation. Head impulse normal bilaterally. No skew. Smooth pursuit slightly choppy but symmetric. Saccades normal latency, accuracy, and velocity. No positional nystagmus on Dix-Hallpike or supine roll. Romberg negative.
Vestibular function tests are requested. Which finding would most argue AGAINST Ménière's and toward vestibular migraine?
Vestibular migraine (definite, Bárány Society 2012/2022 criteria)
- 1.VM and Ménière's overlap substantially: both feature episodic spontaneous vertigo, both can have aural symptoms, both can affect women in midlife. The Bárány Society explicitly acknowledges that some patients meet criteria for both.
- 2.Discriminators favoring VM: bilateral or non-progressive audiogram, migraine features in attacks (headache, photophobia, aura, allodynia), shorter attack durations on average, motion sensitivity in childhood.
- 3.Discriminators favoring Ménière's: unilateral progressive low-frequency SNHL evolving to flat, attack durations more often 1-6 hours, drop attacks (Tumarkin), unilateral caloric weakness.
- 4.When both criteria are met simultaneously, the Bárány Society recommends recording 'Vestibular migraine + Ménière's overlap' rather than forcing one diagnosis.
- 5.Treatment differs substantially: VM responds to migraine prophylaxis (topiramate, propranolol, candesartan); Ménière's to dietary sodium restriction, betahistine in some practices, intratympanic steroids/gentamicin for refractory disease.