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No. 405: December 20, 2017

Chang TP, Hsu YC. Vestibular migraine has higher correlation with carsickness than non-vestibular migraine and Meniere's disease. Acta Neurol Taiwan. 2014 Mar;23(1):4-10.


Background: A close relationship between migraine and vertigo has been postulated for decades, however, it has only been studied extensively in the last 10 years. Vestibular Migraine remains a diagnostic challenge for most clinician's. The prevalence of motion sickness is about 28% in the general population, however there are differences between carsickness, seasickness, and airsickness. It has been recognized for many years that motion sickness and migraine share some common features including female-predominance, similar symptoms, and the same triggers.

Objective: This study compares the rates of carsickness in patients with Vestibular Migraine, Non-vestibular migraine, and Meniere's disease.

Design: Correlational

Methods: Subjects: Consecutive patients with a diagnosis of vestibular migraine, non-vestibular migraine, or Meniere's disease were recruited from Dizziness and Headache Special Clinics from September 2010 to April 2011. All patients underwent a comprehensive history taking and neurological examination. Patients were excluded from the study if: they had an intracranial lesion; if their vestibular symptoms resulted from other vestibular disorders; if they were unable to describe their headache or vertigo well; those with mixed-type headache; and those with major central nervous system disease. All patients were interviewed by two neurologists specializing in vestibular disorders and headache. Carsickness was defined as dizziness, nausea, and/or vomiting provoked by riding in an automobile or a bus. Statistical Analysis: ANOVA was used to analyze age between the groups. Comparisons of gender and the rate of carsickness between the groups were analyzed by chi-square test. The odds ratios of carsickness among each group was also calculated.

Results: Overall, 78.4% of the Vestibular Migraine patients had experienced carsickness in their lifetime. 89.2% of the 'definite Vestibular Migraine' patients, and 70.5% of the 'probably Vestibular Migraine' patients had a history of carsickness compared to 43.6% of the Non-Vestibular Migraine patients, and 18.2% of the Meniere's patients. Among the patients who had experienced carsickness, most had experienced carsickness in childhood before the onset of Vestibular Migraine, Non-Vestibular Migraine, or Meniere's disease.

Conclusion: In the current study, the carsickness rate was highest in those with dVM, followed by pVM and NVM, and lowest in those with MD. The high percentage of lifetime carsickness in the dVM (89.2%) and pVM (70.5%) groups implies that motion sickness is a characteristic of vestibular migraineurs. The high odds ratios of carsickness rate comparing VM to NVM or MD further advocates this viewpoint.

PMID: 24833209

Free PMC Article:

No. 404: December 13, 2017

Bertolini G, Straumann D. Moving in a Moving World: A Review on Vestibular Motion Sickness. Front Neurol. 2016 Feb 15;7:14. doi: 10.3389/fneur.2016.00014. eCollection 2016.


Background: Motion sickness is a common disturbance occurring in healthy people as a physiological response to exposure to motion stimuli that are unexpected on the basis of previous experience. The motion can be either real, and therefore perceived by the vestibular system, or illusory, as in the case of visual illusion. A multitude of studies has been performed in the last decades, substantiating different nauseogenic stimuli, studying their specific characteristics, proposing unifying theories, and testing possible countermeasures. Several reviews focused on one of these aspects; however, the link between specific nauseogenic stimuli and the unifying theories and models is often not clearly detailed. Readers unfamiliar with the topic, but studying a condition that may involve motion sickness, can therefore have difficulties to understand why a specific stimulus will induce motion sickness. So far, this general audience struggles to take advantage of the solid basis provided by existing theories and models. This review focuses on vestibular-only motion sickness, listing the relevant motion stimuli, clarifying the sensory signals involved, and framing them in the context of the current theories.

Objective: This article reviews theories on motion sickness, classifications of motion sickness, describes the vestibular system's involvement, and gives everyday life examples of vestibular motion sickness.

Design: This is a descriptive article focusing on vestibular-only motion sickness.

PMID: 26913019

Free PMC Article:

No. 403: December 6, 2017

Wang J, Lewis RF. Contribution of intravestibular sensory conflict to motion sickness and dizziness in migraine disorders.  J Neurophysiol. 2016 Oct 1;116(4):1586-1591. doi: 10.1152/jn.00345.2016. Epub 2016 Jul 6.


Background: Migraine is associated with enhanced motion sickness susceptibility and can cause episodic vertigo, but the mechanisms relating migraine to these vestibular symptoms remain unclear.

Objective: To test the hypothesis that the central integration of rotational cues (from the semicircular canals) and gravitational cues (from the otolith organs) is abnormal in migraine patients.

Design: Semi-Experimental

Methods: Ten vestibular migraine, migraine, and normal subjects were studied. Subjects sat in a padded chair in complete darkness and were restrained with a harness, and their head was immobilized in the upright orientation with its center aligned with the earth vertical yaw rotational axis. They were accelerated about this rotational axis at 120°·s1·s1 toward their right (clockwise when viewed from above) over 1 s, maintained at a constant angular velocity of 120°/s for 90 s, and then symmetrically decelerated to a stop. Two trials were performed on each subject. Subjects were instructed to tilt their heads as rapidly as possible. At the end of the trial, head orientation was measured with a linear accelerometer to verify that it was upright or tilted in roll by 45 degrees.
Results: Subjects differed significantly with magnitude of eye movement and motion sickness parameters only for motion sickness susceptibility and the normalized axis shift. In both cases, vestibular migraine patients had significantly larger means than migraine or normal subjects, whereas the latter two groups did not differ.

Conclusion: Eye movement responses in Vestibular Migraine patients differed from migraine and normal subjects in three ways: the VOR axis shifts were larger in Vestibular Migraine patients, the normalized axis shift and normalized dumping efficacy were not correlated in VM patients, and the residual conflict in Vestibular Migraine patients was positively correlated with motion sickness susceptibility. 

PMID: 27385797 

No. 402: November 29, 2017

Ekvall Hansson E, Månsson NO, Ringsberg KA, Håkansson A. Dizziness among patients with whiplash-associated disorder: a randomized controlled trial. J Rehabil Med. 2006 Nov;38(6):387-90.


OBJECTIVE: To investigate whether vestibular rehabilitation for patients with whiplash-associated disorder and dizziness had any effect on balance measures and self-perceived handicap.

DESIGN: Randomized, controlled trial.

SUBJECTS: Twenty-nine patients, 20 women and 9 men, age range 22-76 years.

METHODS: The patients were randomized to an intervention group or a control group. The intervention comprised vestibular rehabilitation. All patients were assessed at baseline, after 6 weeks and after 3 months with 4 different balance measures and the Dizziness Handicap Inventory.

RESULTS: After 6 weeks, the intervention group showed statistically significant improvements compared with the control group in the following measures: standing on one leg eyes open (p=0.02), blindfolded tandem stance (p=0.045), Dizziness Handicap Inventory total score (p=0.047), Dizziness Handicap Inventory functional score (p=0.005) and in Dizziness Handicap Inventory physical score (p=0.033). After 3 months, the intervention group showed statistically significant improvements compared with the control group in the following measures: standing on one leg eyes open (p=0.000), tandem stance (p=0.033) and Dizziness Handicap Inventory physical score (p=0.04).

CONCLUSION: Vestibular rehabilitation for patients with whiplash-associated disorder can decrease self-perceived handicap and increase postural control.

PMID: 17067973 

No. 401: November 22, 2017

Hansson EE, Persson L, Malmström EM. Influence of vestibular rehabilitation on neck pain and cervical range of motion among patients with whiplash-associated disorder: a randomized controlled trial. J Rehabil Med. 2013 Sep;45(9):906-10. doi: 10.2340/16501977-1197.


OBJECTIVE: To describe how vestibular rehabilitation influences pain and range of motion among patients with whiplash-associated disorder and dizziness, and to describe whether pain or range of motion correlated with balance performance or self-perceived dizziness handicap.

SUBJECTS: A total of 29 patients, 20 women and 9 men, age range 22-76 years.

METHODS: Patients with whiplash-associated disorder and dizziness were randomized to either intervention (vestibular rehabilitation) or control. Neck pain intensity, cervical range of motion (CROM), balance and self-perceived dizziness handicap were measured at baseline, 6 weeks and 3 months.

RESULTS: There were no differences in neck pain intensity or CROM between the 2 groups either at baseline, 6 weeks or 3 months (p=0.10-0.89). At baseline, neck pain intensity correlated with CROM (-0.406) and self-perceived dizziness handicap (0.492). CROM correlated with self-perceived dizziness handicap and with 1 balance measure (-0.432). Neck pain intensity did not correlate with balance performance (-0.188-0.049).

CONCLUSION: Neck pain intensity and CROM was not influenced by vestibular rehabilitation. Importantly, the programme did not appear to increase pain or decrease neck motion, as initially thought. Neck pain intensity and CROM correlated with self-perceived dizziness handicap. CROM also correlated with 1 balance measure.
PMID: 23974698

No. 400: November 15, 2017

Treleaven J. Dizziness, Unsteadiness, Visual Disturbances, and Sensorimotor Control in Traumatic Neck Pain. J Orthop Sports Phys Ther 2017;47(7):492-502. Epub 16 Jun 2017. doi:10.2519/jospt.2017.7052


Synopsis There is considerable evidence to support the importance of cervical afferent dysfunction in the development of dizziness, unsteadiness, visual disturbances, altered balance, and altered eye and head movement control following neck trauma, especially in those with persistent symptoms. However, there are other possible causes for these symptoms, and secondary adaptive changes should also be considered in differential diagnosis. Understanding the nature of these symptoms and differential diagnosis of their potential origin is important for rehabilitation. In addition to symptoms, the evaluation of potential impairments (altered cervical joint position and movement sense, static and dynamic balance, and ocular mobility and coordination) should become an essential part of the routine assessment of those with traumatic neck pain, including those with concomitant injuries such as concussion and vestibular or visual pathology or deficits. Once adequately assessed, appropriate tailored management should be implemented. Research to further assist differential diagnosis and to understand the most important contributing factors associated with abnormal cervical afferent input and subsequent disturbances to the sensorimotor control system, as well as the most efficacious management of such symptoms and impairments, is important for the future.

PMID: 28622488

No. 399: November 8, 2017

Treleaven J, Peterson G, Ludvigsson ML, Kammerlind AS, Peolsson A.  Balance, dizziness and proprioception in patients with chronic whiplash associated disorders complaining of dizziness: A prospective randomized study comparing three exercise programs. J Orthop Sports Phys Ther. 2017 Jul;47(7):492-502. doi: 10.2519/jospt.2017.7052.


BACKGROUND: Dizziness and unsteadiness are common symptoms following a whiplash injury.

OBJECTIVE: To compare the effect of 3 exercise programs on balance, dizziness, proprioception and pain in patients with chronic whiplashcomplaining of dizziness.

DESIGN: A sub-analysis of a randomized study.

METHODS: One hundred and forty subjects were randomized to either a physiotherapist-guided neck-specific exercise (NSE), physiotherapist-guided neck-specific exercise, with a behavioural approach (NSEB) or prescription of general physical activity (PPA) group. Pre intervention, 3, 6 and 12 months post baseline they completed the University of California Los Angeles Dizziness Questionnaire (UCLA-DQ), Visual Analogue Scales (VAS) for, dizziness at rest and during activity and physical measures (static and dynamic clinical balance tests and head repositioning accuracy (HRA)).

RESULTS: There were significant time by group differences with respect to dizziness during activity and UCLA-Q favouring the physiotherapy led neck specific exercise group with a behavioural approach. Within group analysis of changes over time also revealed significant changes in most variables apart from static balance.

CONCLUSION: Between and within group comparisons suggest that physiotherapist led neck exercise groups including a behavioural approach had advantages in improving measures of dizziness compared with the general physical activity group, although many still complained of dizziness and balance impairment. Future studies should consider exercises specifically designed to address balance, dizziness and cervical proprioception in those with persistent whiplash.

PMID:  26678652

No. 398: November 1, 2017

Ischebeck BK, de Vries J, Van der Geest JN, Janssen M, Van Wingerden JP, Kleinrensink GJ, Frens MA. Eye movements in patients with Whiplash Associated Disorders: a systematic review. Man Ther. 2016 Apr;22:122-30. doi: 10.1016/j.math.2015.10.017.


BACKGROUND: Many people with Whiplash Associated Disorders (WAD) report problems with vision, some of which may be due to impaired eye movements. Better understanding of such impaired eye movements could improve diagnostics and treatment strategies. This systematic review surveys the current evidence on changes in eye movements of patients with WAD and explains how the oculomotor system is tested.

METHODS: Nine electronic data bases were searched for relevant articles from inception until September 2015. All studies which investigated eye movements in patients with WAD and included a healthy control group were screened for inclusion. Qualifying studies were retrieved and independently assessed for methodological quality using the Methodology Checklists provided by the Scottish Intercollegiate Guidelines Network.

RESULTS: Fourteen studies out of 833 unique hits were included. Ten studies reported impaired eye movements in patients with WAD and in four studies no differences compared to healthy controls were found. Different methods of eye movement examination were used in the ten studies: in five studies, the smooth pursuit neck torsion test was positive, in two more the velocity and stability of head movements during eye-coordination tasks were decreased, and in another three studies the cervico-ocular reflex was elevated.

CONCLUSIONS: Overall the reviewed studies show deficits in eye movement in patients with WAD, but studies and results are varied. When comparing the results of the 14 relevant publications, one should realise that there are significant differences in test set-up and patient population. In the majority of studies patients show altered compensatory eye movements and smooth pursuit movements which may impair the coordination of head and eyes.

PMID:  27769215

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