10.14639/0392-100X-N0752
Introduction. Migraine vertigo (MV) and Ménière’s disease (MD) share several signs and symptoms such as tinnitus, fullness, photophobia, phonophobia, headache and vertigo spells lasting hours. Objective. The aim of the present study was to prospectively observe patients with MV with a sporadic audiological symptom evaluated with clinical examination, Vestibular Evoked Myogenic Potentials (VEMPs), ECochG and v-HIT. Results. The finding of VEMP asymmetry, according to our cut-off of 33% of difference between sides, resulted in 20 cases, of which 6 had asymmetry of both c-VEMPs and o- VEMPS, all with development of fluctuating hearing during follow-up. ECochG was positive for endolymphatic hydrops in 12 patients. Conclusions. The evolution of MV may have a variable course in which some patients may develop symptoms typical of MD. The two diseases may be contextually present at the same time configuring an overlapping syndrome, and asymmetric VEMPs might predict development of fluctuating hearing.
application/xml
1827-675X
752
en
Francesco Martines
https://creativecommons.org/licenses/by-nc-nd/4.0
ACTA Otorhinolaryngologica Italica
ECochG
Evolution of migraine vertigo in overlapping syndrome with Ménière’s disease: prognostic role of instrumental examination
Text.Serial.Journal
https://www.actaitalica.it/
41
Vestibology
2021-05-14
2020-03-18
2021-05-17
2021-05-17
180-184
1
Francesco Martines
2021/05/14
10.14639/0392-100X-N0752
180
Istituto Euro-Mediterraneo di Scienza e Tecnologia - IEMEST, Palermo, Italy; Dipartimento di Biomedicina, Neuroscienze e Diagnostica Avanzata, Università degli Studi di Palermo, Italy
1827-675X
ECochG
184
Evolution of migraine vertigo in overlapping syndrome with Ménière’s disease: prognostic role of instrumental examination
https://www.actaitalica.it/article/download/752/581
41
ACTA OTORHINOLARYNGOLOGICA ITALICA 2021;41:180-184; doi: 10.14639/0392-100X-N0752




Vestibology


Evolution of migraine vertigo in overlapping
syndrome with Ménière’s disease: prognostic role
of instrumental examination
Evoluzione dell’emicrania vestibolare in sindrome da sovrapposizione con la malattia
di Ménière: ruolo prognostico degli esami strumentali
Francesco Dispenza1,2, Angelo Immordino3, Roberta Priola3, Pietro Salvago3, Calogero Montalbano3, Francesco Martines2,3
1
 U.O.C. Otorinolaringoiatria, A.U.O. Policlinico P. Giaccone, Palermo, Italy; 2 Istituto Euro-Mediterraneo di Scienza e Tecnologia -
IEMEST, Palermo, Italy; 3 Dipartimento di Biomedicina, Neuroscienze e Diagnostica Avanzata, Università degli Studi di Palermo, Italy


SUMMARY
Introduction. Migraine vertigo (MV) and Ménière’s disease (MD) share several signs
and symptoms such as tinnitus, fullness, photophobia, phonophobia, headache and vertigo
spells lasting hours.
Objective. The aim of the present study was to prospectively observe patients with MV with
a sporadic audiological symptom evaluated with clinical examination, Vestibular Evoked
Myogenic Potentials (VEMPs), ECochG and v-HIT.
Results. The finding of VEMP asymmetry, according to our cut-off of 33% of difference
between sides, resulted in 20 cases, of which 6 had asymmetry of both c-VEMPs and o-
VEMPS, all with development of fluctuating hearing during follow-up. ECochG was posi-
tive for endolymphatic hydrops in 12 patients.
Conclusions. The evolution of MV may have a variable course in which some patients
may develop symptoms typical of MD. The two diseases may be contextually present at the         Received: March 18, 2020
same time configuring an overlapping syndrome, and asymmetric VEMPs might predict               Accepted: October 31, 2020
development of fluctuating hearing.
KEY WORDS: vestibular migraine, Ménière’s disease, overlapping syndrome, vertigo,               Correspondence
VEMPs, ECochG                                                                                   Francesco Dispenza
                                                                                                via Antonio di Rudinì 24/C, 90123 Palermo, Italy
RIASSUNTO                                                                                       E-mail: francesco.dispenza@gmail.com
Introduzione. La vertigine emicranica e la malattia di Ménière condividono diversi segni
e sintomi come acufeni, ovattamento auricolare, fonofobia, cefalea e crisi di vertigine della   Funding
durata di ore.                                                                                  None.
Obiettivo. Lo scopo dello studio è stato quello di valutare prospetticamente i pazienti con
vertigine emicranica e manifestazioni audiologiche sporadiche, mediante esame clinico,          Conflict of interest
VEMPs, ECOchG, v-HIT.                                                                           The Authors declare no conflict of interest.
Risultati. Il riscontro di asimmetria dei VEMPs, secondo il limite del 33% di differenza tra
i due lati, si è avuto in 20 casi dei quali: 6 con asimmetria di ocular e cervical VEMPs e        How to cite this article: Dispenza F, Immordino
sviluppo di fluttuazione uditiva nel corso del follow-up. L’ECochG ha riscontrato un’idrope       A, Priola R, et al. Evolution of migraine vertigo
endolinfatica in 12 pazienti.                                                                     in overlapping syndrome with Ménière’s disease:
Conclusioni. L’evoluzione della vertigine emicranica durante la vita del paziente può ave-        prognostic role of instrumental examination. Ac-
re un decorso variabile nel quale alcuni di essi possono sviluppare sintomi tipici della          ta Otorhinolaryngol Ital 2021;41:180-184. https://
malattia di Meniere. Le due malattie possono essere contestualmente presenti configurando         doi.org/10.14639/0392-100X-N0752
la sindrome da sovrapposizione e l’asimmetria di entrambi i VEMPs potrebbe predire lo
sviluppo della fluttuazione uditiva.                                                            © Società Italiana di Otorinolaringoiatria
                                                                                                e Chirurgia Cervico-Facciale
PAROLE CHIAVE: emicrania vestibolare, malattia di Ménière, sindrome da
sovrapposizione, vertigine, VEMPs, elettrococleografia
                                                                                                               OPEN ACCESS

                                                                                                This is an open access article distributed in accordance with
Introduction                                                                                    the CC-BY-NC-ND (Creative Commons Attribution-Non-
                                                                                                Commercial-NoDerivatives 4.0 International) license. The
Migraine vertigo (MV) and Ménière’s disease (MD) share several signs and                        article can be used by giving appropriate credit and mentio-
                                                                                                ning the license, but only for non-commercial purposes and
symptoms such as tinnitus, fullness, photophobia, phonophobia, headache and                     only in the original version. For further information: https://
                                                                                                creativecommons.org/licenses/by-nc-nd/4.0/deed.en
vertigo spells lasting hours 1,2. Diagnosis of MD or MV is based on anamnes-


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                                                                                                Overlapping syndrome of migraine vertigo and Ménière’s disease




tic data and clinical features, making differential diagnosis                       Otomicroscopy and pure tone audiometry (PTA) testing
very difficult 3.                                                                   bone and air conduction for 0.25-0.5-1-2-3-4 kHz was done
In 2013, the International Headache Society published the                           in all patients. All patients also underwent tympanometry
last classification of headache diseases ICHD3-beta includ-                         and stapedial reflexes study.
ing the up-to-date diagnostic criteria of MV 4, and in 2015                         The exclusion criteria were: previous diagnosis of MD, vestib-
the diagnostic criteria for MD are codified by the European                         ular schwannoma of VIII cranial nerve, benign paroxysmal po-
Academy of Otology and Neurotology 5; both classifications                          sitional vertigo, head trauma, middle ear diseases, conductive
are used widely to diagnose these two diseases (Tab. I).                            hearing loss (i.e. suspect for otosclerosis), sensorineural hear-
However, in clinical practice, several patients exhibit features                    ing loss, labyrinthine fistula, ototoxic drug exposure, barotrau-
of both diseases. Murofushi et al. defined such patients as                         ma, middle and inner ear malformations, chronic neuropathy
suffering from an overlapping syndrome of MD and MV 6.                              (i.e. diabetes, demyelinating disease, chronic renal failure) and
The aim of the present study was to prospectively observe                           alteration of stapedial reflex or type B and C tympanogram.
a series of patients with definite MV having some sporadic                          Clinical vestibular examination included: searching for
audiological symptom (i.e. tinnitus, fullness), but normal                          spontaneous nystagmus with video-Frenzel, Dix-Hallpike
hearing, and followed-up with electrophysiological and                              test and supine roll test to exclude positional vertigo, head
clinical tests. All instrumental findings were then corre-
                                                                                    shaking test, head impulse test, skew test and Romberg test.
lated with clinical behaviour.
                                                                                    Cervical and Ocular VEMPs (c-VEMPs and o-VEMPs)
                                                                                    were recorded in all patients with Socrates, Hedera Bio-
Materials and methods                                                               medics S.r.l. with biofeedback of muscle contraction on the
Among all patients with vestibular diseases who referred to                         monitor. Biofeedback is used to reduce the variability in
our Laboratory of Acoustic Electrophysiology and Vestibol-                          case of difference in muscle contraction between sides. It
ogy in 2016, we prospectively evaluated patients matching                           is achieved through a digital LED and displayed waveform
criteria for MV reported by ICHD3-beta and Barany Society.                          rectification, for a realistic comparison between the ipsi-
All patients had focused clinical history: number of severe                         and contralateral amplitudes.
vertigo spells, dizziness evaluated with Dizziness Handicap                         Regarding o-VEMPs, the negative electrode was positioned
Inventory Italian validated version 7, subjective tinnitus,                         under the eye contralateral to the acoustic stimulation side
fullness, subjective hearing loss and fluctuating hearing,                          and the positive electrode a few mm under the negative one,
aura symptom, triggers for headache and vertigo, anxiety,                           with the ground electrode on the forehead. The patient was
motion sickness and ascertained food intolerance.                                   in a supine position and the recording started by asking pa-

Table I. Diagnostic criteria for vestibular migraine and Ménière’s disease according to the last available classification.
    International classification headache disease 3-beta: vestibular                               European Academy Otology Neurotology
                         migraine diagnostic criteria                                                 Ménière’s disease diagnostic criteria
                              1. Vestibular migraine                                                        1. Definite Ménière’s disease
 A. At least 5 episodes with vestibular symptoms of moderate or severe              A. Two or more spontaneous episodes of vertigo, each lasting 20 minutes to
 intensity, lasting 5 minutes to 72 hours                                           12 hours
 B. Current or previous history of migraine with or without aura according to       B. Audiometrically documented low- to medium-frequency sensorineural
 the ICHD                                                                           hearing loss in the affected ear on at least one occasion before, during or
                                                                                    after one episodes of vertigo
 C. One or more migraine features with at least 50% of the vestibular episodes:     C. Fluctuating aural symptoms (hearing, tinnitus or fullness) in the affected
 Headache with at least two of the following characteristics: one sided location, ear
 pulsating quality, moderate or severe pain intensity, aggravation by routine
 physical activity
 Photophobia and phonophobia
 Visual aura
 D. Not better accounted for by another vestibular or ICHD diagnosis                D Not better accounted for by another vestibular diagnosis
                         2. Probable vestibular migraine                                                    2. Probable Ménière’s disease
 A. At least 5 episodes with vestibular symptoms of moderate or severe              A. Two or more episodes of vertigo or dizziness, each lasting 20 minutes to
 intensity, lasting 5 minutes to 72 hours                                           24 hours
 B. Only one of the criteria B and C for vestibular migraine is fulfilled (migraine B. Fluctuating aural symptoms (hearing, tinnitus or fullness) in the reported
 history or migraine features during the episode)                                   ear
 C. Not better accounted for by another vestibular or ICHD diagnosis                C. Not better accounted for by another vestibular diagnosis




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F. Dispenza et al.




Table II. Clinical features and symptoms in the sample.
 Headache features               Started several years before vertigo spells   Contextually with vertigo spells   Immediately before vertigo spells
                                                   16/30                                   10/30                               4/30
 Accompanying headache                          Visual aura                            Photophobia                         Phonophobia
 symptoms                                          12/30                                   30/30                              26/30
 Hearing symptoms developed                       Tinnitus                                Fullness                  Sensorineural hearing loss
 during follow-up                                  10/30                                   20/30                               4/30
 Other symptoms                            Persistent dizziness                       Motion sickness                         Anxiety
                                                   20/30                                   20/30                              26/30


tient to fix a point about 30° over the head with a distance                     test. Our IRB approved this clinical study and the work was
of 1 metre. c-VEMPs were recorded with the negative elec-                        carried out in accordance with The Code of Ethics of the
trode at the middle third of the sternocleidomastoid muscle                      World Medical Association (Declaration of Helsinki).
ipsilateral to the acoustic stimuli, the positive electrode on
the middle third of the clavicle and the ground electrode                        Results
on the forehead; the patient was lying in a supine position
with the head rotate contralateral to the acoustic stimuli                       Thirty patients matched inclusion/exclusion criteria and were
and the recording was started by asking the patient to flex                      prospectively followed-up after first examination. The mean
the head to the sternum maintaining the position during the                      age was 45 years (range 18-64 years), with 24 females and 6
examination. The acoustic stimuli were air conducted by                          males. All patients complained of migraine headache: 16 pa-
earphone inserts as tone burst 500 Hz, 120 dB SPL and                            tients had migraine for years (average 18 years) before vertigo
                                                                                 spells, 10 patients had headache contextually to vertigo and in
repeated 200 times. For each patient, the presence and re-
                                                                                 4 subjects the vertigo spells preceded the headache (average
peatability of the curve and amplitude and latency of the
                                                                                 3 years). Eight patients had family history for vertigo, 6 for
p10-n10 complex for o-VEMPs and p13-n23 complex for
                                                                                 migraine alone and 6 for migraine and vertigo.
c-VEMPs were evaluated; the asymmetry between two
                                                                                 The visual aura was reported in 12 cases; photophobia was
sides over 33% was considered as pathological 8.
                                                                                 present in all cases, and 26 patients also had phonophobia. Mo-
The electrocochleography (ECochG) was recorded with
                                                                                 tion sickness was present in 20 cases; anxiety was present in 26
Socrates, Hedera Biomedics S.r.l. by an extratympanic
                                                                                 patients and 16 patients reported documented food intolerance.
Lilly TM-Wick electrode as positive, ground electrode on
                                                                                 The symptoms referred by patients are summarised in Table II.
the forehead and the negative electrode on the contralateral                     All patients had normal hearing after first PTA evaluation;
mastoid tip. The acoustic stimuli were air conducted by                          10 patients complained of episodic tinnitus and 20 of tran-
earphone inserts with click stimuli 120 dB SPL, alternating                      sitory fullness sensation, among which 9 had both symp-
polarity, rhythm 5,4 msec repeated 2000 times. Both ears                         toms. Twenty patients reported dizziness and unsteadiness.
were tested. On the curve obtained, the SP/AP ratio was                          All cases had normal gain on v-HIT examination.
evaluated considering as pathological a result over 0.5.                         In all patients it was possible to record VEMPs. All latency
The video Head Impulse Test (v-HIT) was done with Eye-See-                       and amplitude values were within the normal range. The
Cam System Interacoustic. The patient was in a sitting position                  finding of VEMPs asymmetry, according to our cut-off of
in front of a point to fix a 1.5 metre distance while the operator               33% of difference between sides, resulted in 20 cases, of
casually rotated the head to the right and to the left. The test                 which 6 with asymmetry of both c-VEMPs and o-VEMPS,
was considered complete after 20 impulses were accepted. The                     8 with asymmetric c-VEMPs alone and 6 with asymmetric
vestibular-ocular reflex (VOR) gain was considered as patho-                     o-VEMPs. Ten patients had normal and symmetric VEMPs
logical if less than 0.8 and if more than 5% of asymmetry.                       response. The asymmetric response more than 33% re-
The minimum follow-up considered was 24 months since                             sulted in a difference in amplitudes between the two sides,
first examination with scheduled revaluation at 6, 12, 18                        although the values of amplitude were in the normative
and 24 months; the record was updated in the event that a                        range: 120 ± 50 mV for c-VEMP and 5 ± 2 mV for o-VEMP.
symptom arose or worsened, or if the instrumental score                          In 12 cases, the first ECochG showed a unilateral hydrops
had modifications. The patients were alerted to call our                         because the SP/AP ratio was more than 0.5. The ECochG
centre in case of sudden hearing worsening or some modifi-                       did not show a significant relationship between fluctuat-
cation in their symptoms. Statistical analysis was done with                     ing hearing and SP/AP alteration, and patients with an SP/
MS Excel performing Chi-squared test and Fisher’s exact                          AP ratio more than 0.5 at first examination maintained the



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                                                                                            Overlapping syndrome of migraine vertigo and Ménière’s disease




Table III. VEMPs asymmetry evaluation in patients with fluctuating hearing during 2 years of follow-up. Asymmetry of both VEMPs was predictive of fluctuating
hearing developed in the side with relatively low amplitude.
 VEMPs asymmetry > 33%                             c-VEMPs                   o-VEMPs                 c-VEMPs and o-VEMPs             Total patients
 Fluctuating hearing                               2                             4                            6                             12
 Normal hearing                                    4                             4                            0                              8
                                                p > 0.05                      p > 0.05                     p < 0.05                         20


same score at further controls. Twelve patients with altered                     with migraine symptoms could imply a challenging dif-
ECochG had VEMPs amplitude and latency in the normal                             ferential diagnosis with MD 1. For these reasons, an over-
range, but all had both c- and o-VEMPs asymmetry > 33%,                          lapping syndrome was hypothesised in patients that match
with the affected ear showing relatively low amplitude.                          both clinical classifications based on referred symptoms 6,10.
During follow-up, the score of instrumental examination                          Our prospective evaluation of MV patients highlighted that
(v-HIT, VEMPs and ECochG) of all patients was repeat-                            asymmetry of both VEMPs could be a predictor of poten-
able and without significant modification. In 16 patients a                      tial development of an overlapping syndrome with MD.
fluctuation of sensorineural hearing level was documented                        Several studies have attempted to find a gold standard test that
at PTA and in 4 cases among these the sensorineural hear-                        could differentiate VM, MD and non-vestibular migraine 13-17.
ing loss become stable at an average of 40 dB. In 18 pa-                         The calculation of the SP/AP ratio through electrocochleog-
tients re-evaluated for acute vertigo, the spell did not have a                  raphy (EcochG) has often been reported to be an objective
noticeable nystagmus at the moment of the visit and repeat                       index of endolymphatic hydrops in MD, even though it is
instrumental examination did not show any changes.                               limited by low sensitivity and its reliability is strictly depend-
Statistical analysis was carried out to search for a rela-                       ent on the EcochG technique used, type of stimulus given and
tionship between fluctuations of hearing and clinical or                         stage of MD. In contrast, scarce data are available relative to
instrumental features. The presence of asymmetry of both                         the use of EcochG in patients with VM. As in the present se-
o-VEMPS and c-VEMPs was significantly related to fluc-                           ries of patients, Vitkovic et al. studied 523 patients and found
tuating hearing (p < 0.05). The data are summarised in Ta-                       no difference in EcochG test results between VM and MD
ble III. Fluctuating hearing was found in the same side of                       patients 13. Lotfi et al. also observed no relevant EcochG dif-
low amplitude of VEMPs.                                                          ferences between patients with VM and healthy subjects in a
                                                                                 case series of 20 patients 14. In contrast, Yollu et al. reported
                                                                                 higher SP/AP ratios among patients with VM with respect to
Discussion
                                                                                 migraineurs without complaints of vertigo 16.
This study focused on patients suffering for MV meeting                          As is known, c-VEMPs is the first instrumental test that
ICDH3-beta criteria. This clinical entity, like migraine head-                   shows some alteration in MD due to early involvement of
ache, is predominant in women (24/30 in our series) in the 3rd                   the saccule by endolymphatic hydrops with high sensitivity
and 4th decade of life. Family predisposition is present in about                of the macula to low frequency 17,18.
half of MV patients of our experience, and a possible autoso-                    In patients with MV, the results of c-VEMPs are conflict-
mal dominant genetic transmission may be responsible 9.                          ing without unique interpretations. Boldingh et al. reported
Photophobia and phonophobia are two symptoms frequently                          43% of their cases had absent potential 19. Liao and Young
described by MV patients, as in our series where they were                       evaluated 20 patients with basilar artery migraine with diz-
present in about 90% of cases 10. Motion sickness was reported                   ziness and c-VEMPs were absent in 35% of cases 20.
as a frequent symptom in all MV patients by Pagnini et al. 11;                   Zaleski et al. found no difference in c-VEMPs between MV
in our findings, 66% of patients complained of this symptom.                     patients and controls, but they reported the absence of o-
The study of vestibular-oculomotor reflex with v-HIT in                          VEMPs in 28% of cases and low amplitude or asymmetry
our series was normal in all subjects with MV, including                         in large majority of MV patients 21.
those who developed fluctuation of hearing during follow-                        However, alteration of o-VEMPs are variously described in
up. v-HIT applied to MV patients did not show a clinical                         the literature with contradictory results. Makowiec et al. re-
importance as reported by ElSherif et al. who compared                           ported that 51 patients among 83 with MV had asymmetry of
healthy subjects and MV patients and found no alterations                        o-VEMPs, while Zuniga et al. found no difference in amplitude
in gain or other parameters, underscoring the normality of                       of o-VEMPs between MV patients and normal subjects 22,23.
vestibular-ocular reflex in MV patients 12.                                      Hearing in MV patients is in line with general population; on
Often MV patients complain of hearing issues like fullness,                      the contrary, in MD hearing loss is a parameter required to
tinnitus and even hearing loss. These symptoms associated                        achieve a diagnosis 4. The fluctuating hearing in some of our


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F. Dispenza et al.




patients during follow-up could indicate a possible correlation               6
                                                                                   Murofushi T, Tsubota M, Kitao K, et al. Simultaneous presentation of
                                                                                   definite vestibular migraine and definite Ménière’s disease: overlap-
between both c-VEMPs and o-VEMPs findings and clinical                             ping syndrome of two diseases. Front Neurol 2018;9:749. https://doi.
behaviour of MV over time. The documented fluctuation of                           org/10.3389/fneur.2018.00749
hearing associated with vertigo spells lasting hours, which                   7
                                                                                   Nola G, Mostardini C, Salvi C, et al. Validity of Italian adaptation of the
we recorded in some MV patients during follow-up, is more                          Dizziness Handicap Inventory (DHI) and evaluation of the quality of life in
                                                                                   patients with acute dizziness. Acta Otorhinolaryngol Ital 2010;30:190-197.
typical for MD compared to MV. In our opinion, some MV                        8
                                                                                   Dispenza F, Mazzucco W, Mazzola S, et al. Observational study on
patients may develop MD as an evolution of a latent inner                          risk factors determining residual dizziness after successful benign
ear disease, which for a period of time manifests only with                        paroxysmal positional vertigo treatment: the role of subclinical BP-
migraine-associated vertigo. Another possible explication                          PV. Acta Otorhinolaryngologica Ital 2019;39:347-352. https://doi.
                                                                                   org/10.14639/0392-100X-2247
could be that MD is latent for a phase of life and manifests                  9
                                                                                   Bahmad F, DePalma SR, Merchant SN, et al. Locus for fa-
with MV-like symptomatology. According to findings of Ma-                          milial migrainous vertigo disease maps to chromosome 5q35.
kowiec et al. 23, a patient with MV is likely to have abnormal                     Ann Otol Rhinol Laryngol 2009;118:670-676. https://doi.
                                                                                   org/10.1177/000348940911800912
o-VEMPs and normal c-VEMPs and most patients with MD                          10
                                                                                   Lopez-Escamez JA, Dlugaiczyk J, Jacobs J, et al. Accompany-
have alterations of c-VEMPs. Although our data are limited by                      ing symptoms overlap during attacks in Ménière’s disease and ves-
the small number of cases observed, in our series it was noted                     tibular migraine. Front Neurol 2014;5:265. https://doi.org/10.3389/
that a patient with MV symptoms with both o-VEMPs and                              fneur.2014.00265
                                                                              11
                                                                                   Pagnini P, Verrecchia L, Giannoni B, et al. Migraine-related vertigo
c-VEMPs asymmetry already has or will develop MD during                            (MV). Acta Otorhinolaryngol Ital 2003;23:19-27.
their lifetime 15.                                                            12
                                                                                   ElSherif M, Reda MI, Saadallah H, et al. Video head impulse test
                                                                                   (vHIT) in migraine dizziness. J Otol 2018;13:65-67. https://doi.
                                                                                   org/10.1016/j.joto.2017.12.002.
Conclusions                                                                   13
                                                                                   Vitkovic J, Paine M, Rance G. Neuro-otological findings in patients
The evolution of MV during the life of patients can have vari-                     with migraine- and nonmigraine-related dizziness. Audiol Neurootol
                                                                                   2008;13:113-122. https://doi.org/10.1159/000111783
able progression in which some may develop symptoms typi-                     14
                                                                                   Lotfi Y, Mardani N, Rezazade N, et al. Vestibular function in patients
cal of MD. The two diseases can be contextually present at                         with vestibular migraine. Aud Vest Res 2016;25:166-174.
the same time, configuring an overlapping syndrome. This                      15
                                                                                   Martines F, Dispenza F, Montalbano C, et al. Comparison of elect-
condition is an expression of some alterations in the inner ear.                   rocochleography and video head impulse test findings in vestibular
                                                                                   migraine and Ménière disease: a preliminary study. Int Adv Otol
The instrumental evaluation of inner ear functions provides                        2020;16:183-189. https://doi.org/10.5152/iao.2020.8165
information about the status of the system and the asymmetry                  16
                                                                                   Yollu U, Uluduz DU, Yilmaz M, et al. Vestibular migraine screening
of both c- and o-VEMPs, although as observed in our small                          in a migraine-diagnosed patient population, and assessment of ves-
                                                                                   tibulocochlear function. Clin Otolaryngol 2017;42:225-233. https://
series, seems to be related to a high risk of developing fluc-                     doi.org/10.1111/coa.12699
tuating hearing during the course of MV. Further study on a                   17
                                                                                   Maxwell R, Jerin C, Gurkov R. Utilisation of multi-frequency
larger number of patients could help to better explain the link                    VEMPs improves diagnostic accuracy for Ménière’s disease. Eur
between MV and MD.                                                                 Arch Otorhinolaryngol 2017;274:85-93. https://doi.org/10.1007/
                                                                                   s00405-016-4206-z
                                                                              18
                                                                                   Scarpa A, Gioacchini FM, Cassandro E, et al. Clinical application of
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    ves-150549                                                                     mao.0000000000001880



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