Vestibular Migraine Post Hysterectomy

Migraine effects far more females than males, 3:1 and has long been recognizedVestibular Migraine Post Hysterectomy to have hormonal triggers. Females typically experience the onset of migraine (with and without aura) at puberty and often see a reduction in symptoms post menopause. The literature suggests however, that post hysterectomy (surgical menopause) approximately 45% of patients’ report that their symptoms actually got worse.

Dizziness and vertigo is a common aura (25%) associated with migraine, as is hypersensitivity to light, sound and nausea (75%). The following is a case study of a patient recently seen at AIB

History: 50 year-old female referred by PCP and ENT. Lifelong issues associated with menstrual migraine including motion intolerance. No prior history of otologic, cardiovascular or neurologic conditions. Patient underwent a hysterectomy in May 2012 and in November began to have episodes of vertigo without auditory symptoms, but with hypersensitivity to light, sound and movement with nausea.

Examination: Patient seen January 2013. CTSIB balance function, VNG, VEMP, Dynamic Visual Acuity and prior ENT and Audiological evaluations were unremarkable. * Caveat – it has been reported that up to 30-50% of migraine patients present with a unilateral caloric weakness. This may be more related to vestibulo-cerebellar origins than labyrinthine, secondary to migraine.

Recommendations: The nature of her sudden onset of symptoms and negative ENT and peripheral vestibular findings strongly suggested the trigger was likely the “instant menopause effect” and she was encouraged to return to her OB/GYN

Follow-up and Outcome: See the patient’s statement below reporting her status and the importance of a team approach in managing these complex patients.

 “I came to your office, as a last resort, trying to track down the cause of what had become almost debilitating dizziness.  After ruling out all other causes, you shared with me that the “instant menopause” I had been experiencing after a recent hysterectomy, and the likely hormone imbalance, was the culprit.  As soon as I returned home, I visited my ob/gyn and we found that my estrogen hrt needed to be complemented by progesterone as well.  Within six days my dizziness and all of the related migraine symptoms I had been experiencing disappeared!  I have followed a regimen of daily estrogen/progesterone combined with about 8mg of prophylactic Topamax for the past five months, and I feel like I have my life back. I cannot tell you how grateful I am to you for helping me through the worst health issue I’ve ever faced.

     Again, please know that I am very, very, grateful, and that I will continue to spread the word as well.  It changed my life to finally have this addressed and I am just so thankful!”

– J.S., Estero, FL


 References and Readings

  1. Headache Classification Subcommittee of the International Headache Society. The International Classification of Headache Disorders: 2nd edition. Cephalgia 2004;24(Suppl 1):9-160.
  2. MacGregor EA. Migraine headache in perimenopausal and menopausal women. Curr Pain Headache Rep2009;13:399-403.
  3. Martin VT, Behbehani M. Ovarian hormones and migraine headache: understanding mechanisms and pathogenesis—part 2. Headache 2006;46:365-386.
  4. Shuster L, Faubion S, Sood R, Casey P. Hormonal manipulation strategies in the management of menstrual migraine and other hormonally related headaches. Curr Neurol Neurosci Rep 2011;11:131-138.
  5. Pringsheim T, Davenport WJ, Dodick D. Acute treatment and prevention of menstrually related migraine headache: evidence-based review. Neurology 2008:70;1555-1563.
  6. Roberts R, Gans R, Kastner A. Differentiation of migrainous positional vertigo (MPV) from horizontal canal benign paroxysmal positional vertigo (HC-BPPV). International Journal of Audiology 2006, 45, 224-226