Migraine-anxiety related dizziness (MARD): a new disorder? as originally seen in the Journal of Neurology, Neurosurgery and Psychiatry
This is an older article, but I’ve had several patients with vestibular complaints that had migraine and/or anxiety in their history, either documented or in their own verbal history. I wanted to understand this phenomena better, so I can better serve this population. And, as always, ya’ll tag along on my personal improvement projects. I used the above article and also attacked the migraine and psychogenic dizziness sections in Herdman’s Vestibular Rehabilitation.
While dizziness or vertigo (which I’m going to lump into just “dizziness” for simplicity’s sake) is a common associated symptom with migraine (about 54.5% of migraine sufferers complain of concurrent dizziness, about half of them with every migraine and others with only some migraines) it is not a required symptom to be diagnosed with migraine. It seems to fall into the category of a migraine aura. Many “migraineurs” will show positive signs of vestibular deficits, even if they don’t complain of dizziness.
About 40-50% of dizziness complainers have a psychological comorbidity. Of those, the psychological component is playing a serious role in the dizziness about half (HALF!) the time. The most prominent culprit being an anxiety disorder (including phobias, PTSD, generalized anxiety, obsessive-compulsive, panic attacks with and without agoraphobia (fear of embarrassment)), followed by somatization (which sounds an awful lot like your hyperchondriacs to me) and then depressive disorders (major depressive, bipolar, etc.). You can describe the dizziness symptom as “psychogenic dizziness” if there are no vestibular test abnormalities and only if the person is not diagnosed with a panic disorder. Dizziness is a required feature of a panic disorder diagnosis. The question, which hasn’t been satisfactorily answered is: which came first the psychological problem or the vestibular problem? Which is driving the other? The answer to this question would be helpful in driving treatment, but since we don’t know, we’ll want to treat both.
There is also a certain category of folk that are close to these: the conversion disorder, factitious disorder and malingering people. Conversion disorder has symptoms of a neurological disorder effecting sensation or voluntary motor function, but has no relationship to a defined disorder AND the person has no conscious intention of producing the symptom. Where as with factitious disorder, they are intentionally trying to trick you, but not for any external gain. These are the people who WANT to be “the sick person” in their family/friends. Then there’s the malingering folk who are also trying to pull the proverbial wool over your eyes for an external gain, usually monetary.
So what are we to do with these migraine-anxiety dizziness folk? First, we can begin addressing their problem. So many dizzy patients are looked at in the medical community as complete nutters. So the ones we can identify as truly having a problem, just saying, “Yes, I see you and your problem. Here’s what we’re going to do about it.” Is half the battle for the person. So just a typical strengthening and balance program can go a long way. Your more specific clinical interventions will involve reducing their visual dependence as this population tends to be VERY visually dependent. Herdman recommended starting treatment with stress management including:
— an aerobic exercise program at the end of the day 3-4 times/week for at least 20 mins (which may need to be worked up to).
— avoiding hypoglycemia, so eating a little something every 8 hours. No more skipping breakfast and eating at regular intervals, even on the weekends.
— make a regular sleep schedule– go to sleep and wake up at roughly the same time everyday.
They also need to quit all types of nicotine and suggest talking with their physician about the possibility of titrating down any estrogen they’re taking including contraceptives and estrogen replacements. Diet can also play an big role in migraines. Click here to see what a migraine diet entails. A diary to record date and time of an attack or headache and any foods from the avoid list that they consumed in the last 24 hours is also helpful. That way the person can begin to whittle down what of the dozens of foods that could be triggers are specifically triggering them. And of course, take any medications the physician has prescribed and in the manner it is prescribed.
For the anxiety portion, once the patient has been coming for a few sessions and a little rapport and trust has been established between the client and therapist, you can open the door to perhaps involving a psychological professional as well. You can phrase it in a way like, “Remember how we started talking about bringing down your stress levels on our [first/second/third] visit? Stress and the emotions it creates can trigger symptoms of balance problems in about half of people that have balance problems. You seem to be improving well with your balance exercises and we’re going to keep working on them. You may want to consider talking with a counselor too to make sure we’re addressing every part of your balance.” The text said to state the prevalence of psychological disorders in dizziness, assure them that the plan is to keep working on their balance and relate it back to the stress.
Between the article and the text, I learned a lot! I fully intend to be using that information next week. I need to develop a handout of those homework items. To work!