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134 BAlAnCE FunCtion AssEssmEnt And mAnAgEmEnt
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Vestibular Migraines and
Ménière’s Disease
Patients with Ménière’s disease have a higher prevalence of migraines than the general population (Radtke
et al., 2002). Multiple studies have shown that patients
often present with features of both vestibular migraines
and Ménière’s disease. During Ménière’s attacks,
patients have noted aura, photophobia, and migraines,
and similarly, patients with vestibular migraine report
aural fullness, hearing loss, and tinnitus (Lempert,
2013). These diagnoses commonly overlap and are difficult to differentiate; however, the cause of the relationship is not well understood.
CONCLUSION
There are several clinical clues that can help lead an
astute clinician to a patient’s diagnosis when presenting with symptoms of dizziness. In our experience, the
history is a critically important component of the interaction because many causes of dizziness can often be
clinically diagnosed. Listening carefully to the description and timing of the sensation, associated symptoms,
and exacerbating factors, it may be possible to arrive
at an accurate differential diagnosis. Additionally, it is
always important to remain cognizant of concerning
signs of dangerous cardiac or neurologic disorders when
taking the history. The dizziness questionnaire, specifically if it is completed prior to the clinic visit, allows for
proper diagnosis and maximal time efficiency, and can
provide critical information about the patient’s experience and help direct the clinician’s interview.
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Appendix 6–A
Washington University in St. Louis School of Medicine
Department of Otolaryngology-Head and Neck Surgery
Dizziness and Balance Center
Name: D.O.B.
Please describe in your own words, the sensation you feel without using the word “dizzy”:
Please circle the symptom that brought you here today:
Spinning in circles Falling to one side World spinning around me
Please circle:
YES NO
YES NO I am dizzier in certain positions
YES NO I am free from dizziness between attacks
YES NO My hearing changes with an attack
YES NO I am dizzy if I stand up quickly
YES NO I am nauseated during an attack
YES NO I have had a recent cold or flu
YES NO I have had fullness, pressure, or ringing in my ears
YES NO I have had pain or discharge in my ears
YES NO I have trouble walking in the dark
YES NO I am better if I sit or lie perfectly still
YES NO Loud sounds make me dizzy
YES NO I black out or faint when dizzy
My dizzy spells come in attacks
Date of first attack:
How often:
How long is the attack:
Which position:
YES NO I have severe or recurrent headaches
YES NO I am sensitive to light during my headaches and/or dizziness
YES NO I have double or blurry vision
YES NO I have numbness in my face or extremities
continues
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appendix 7–a. continued
YES NO I have weakness or clumsiness in my arms/legs
YES NO I have slurred or difficult speech
YES NO I have difficulty swallowing
YES NO I have tingling around my mouth
YES NO I see spots before my eyes
YES NO I have jerking of my arms/legs
YES NO I have seizures
YES NO I have confusion or memory loss
YES NO I have had recent head trauma
The following refer to your hearing. Indicate which side has been affected:
YES NO I have difficulty hearing Left Right Both
YES NO I have ringing Left Right Both
YES NO I have fullness Left Right Both
YES NO I have a change Left Right Both
Have you had any of the following:
YES NO Pain in ears Left Right Both
YES NO Discharge in ears Left Right Both
YES NO Exposure to loud noise Left Right Both
YES NO Ear infections Left Right Both
YES NO Trauma to ears Left Right Both
YES NO Previous ear surgery Left Right Both
Describe:
YES NO I have a family history of deafness Left Right Both
The following refer to habits and lifestyle:
YES NO There is added stress to my life recently
YES NO I am dizzy or unsteady constantly
My dizziness is related to:
YES NO Moments of stress
YES NO Menstrual period
YES NO Overwork or exertion
YES NO I feel lightheaded or “swimming” sensation when I am dizzy
YES NO I breathe faster or deeper when excited or dizzy
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YES NO I recently changed eyeglasses
YES NO I feel weak or faint a few hours after eating
YES NO I drink coffee
How much
YES NO I drink tea
How much
YES NO I drink soft drinks
How much
YES NO I drink alcohol
How much
YES NO I smoke
What How much
YES NO I previously smoked
What How much
MEDICAL HISTORY:
Please list your current medical problems and length of illness:
Please list all surgery performed and approximate date:
Please list all allergies (including drugs) and reaction:
Please list all medications you currently take (including over the counter meds):
Please list previous testing (hearing, x-rays, head scans, etc.):
continues
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appendix 7–a. continued
FAMILY HISTORY: (Please specify relationship to you)
YES NO
YES NO
YES NO
YES NO
YES NO
YES NO
YES NO
YES NO
SYSTEM REVIEW:
Circle all symptoms you currently experience:
Constitutional: Eyes:
Recent weight change Loss of vision
Fever Pain
Fatigue Discharge/tearing
Migraine
High blood pressure
Low blood pressure
Diabetes
Low blood sugar
Thyroid disease
Asthma
Other diseases
Ear, Nose, Mouth, Throat:
Itchy ears Nasal obstruction Drooling
Nosebleed Sneezing Stuffy nose
Loss of sense of smell Growth in nose Bleeding from throat
Mouth growth, ulcer Chewing difficulty Lump in neck
Pain on swallowing Heartburn Sore throat
Voice changes Breathing difficulty Nasal discharge
Facial weakness Snoring Dental problems
Cardiovascular: Respiratory:
Chest pain Wheezing
Irregular heart beat Cough
Swelling of legs Shortness of breath
Leg pain with walking Mucus
Leg pain with rest Coughing up blood
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Gastrointestinal: Musculoskeletal:
Decrease in appetite Neck pain
Diarrhea/Constipation Joint pain/Stiffness
Nausea/Vomiting Arthritis
Indigestion
Blood in stool
Food intolerance
Skin: Neurological:
Rash Headache
Jaundice Tremor
Recent Baldness Blackout
Psychiatric: Endocrine:
Insomnia Thyroid trouble
Depression Heat/Cold intolerance
name joint(s)
Seizures
Paralysis
Excessive sweating
Excessive thirst, hunger, urination
Genitourinary: Hematologic/Lymphatic:
Painful urination Bleeding problems
Difficulty passing urine Anemia
Venereal disease Easy bruising
Incontinence Blood disorder
Blood in urine
Frequent urination at night
Do you have anything else to tell us about your problem that we have not asked on this questionnaire?
______________________________________________________ _____________________
Provider Signature Date
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8
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Assessing Dizziness-Related
Quality of Life
Erin G. Piker, Gary P. Jacobson, and Craig W. Newman
introduCtion
This chapter presents a description of the tools that
are available to measure dizziness-related quality of
life (DRQoL). The reasons to measure DRQoL in the
context of the balance function assessment are discussed. Some of the more commonly used measures
are described. Last, we illustrate how DRQoL measures
have been used in clinic-based research.
Why is it important to measure a patient’s DRQoL?
There are at least three answers to that question. First,
based on past research it has been shown repeatedly
that measures of impairment (e.g., caloric test results)
do not correlate significantly with measures of DRQoL
unless the loss of peripheral vestibular system function
is profound and bilateral (Jacobson & Calder, 2000).
So, with few notable exceptions, we know that DRQoL
measures represent unique information that cannot be
predicted based on measures of impairment. For example, the magnitude of caloric asymmetry does not correlate with measures of DRQoL. Neither phase, gain,
nor vestibulo-ocular reflex (VOR) asymmetry measures correlate with DRQoL measures. Moreover, cervical or ocular vestibular evoked myogenic potential
(i.e., cVEMP, oVEMP) latency or amplitude measures
do not predict DRQoL measures (McCaslin, Jacobson,
Grantham, Piker, & Verghese, 2011; Pelosi et al., 2013;
Piker, Jacobson, McCaslin, & Grantham, 2008).
A second reason to administer DRQoL measures is
to demonstrate to payers that the services we offer are
efficacious. These can be diagnostic services that lead
to accurate diagnosis and treatment. Further, administration of DRQoL measures used in pre- versus posttreatment paradigms help to quantify benefit received
from medical, surgical, and/or rehabilitative services.
A final reason to administer DRQoL measures is
to obtain information that can lead to the correct diagnosis. An excellent example is a disease called persistent postural perceptual dizziness (PPPD). PPPD often
occurs secondary to a significant anxiety disorder that
may or may not coexist with a vestibular impairment.
These patients often do not complain of true vertigo
but instead complain of continuous dizziness. For this
group of patients, the administration of a self-report
measure of anxiety, and the information derived from
that measure, may lead to targeted and accurate treatment (e.g., the administration of an anxiolytic medication) of the patient.
In this chapter we describe the evolution of the
World Health Organization’s (WHO) classification
scheme in quantifying DRQoL. The psychometric characteristics of an acceptable measurement device are
briefly described. A comprehensive list of dizzinessspecific questionnaires currently available to clinicians
and researchers is provided, as well as a list of commonly used generic questionnaires. The scoring/interpretation and application of the most commonly used
instruments to assess DRQoL are presented. Finally,
representative data obtained from studies employing
dizziness questionnaires in pre and post-treatment paradigms are described. The latter application for documenting treatment efficacy is especially important in
light of today’s health care environment.
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