Cha, Yoon‐Hee

In 2007, the Bárány Society embarked on a project to establish definitions of vestibular syndromes and disorders based on best available evidence, referred to as the International Classification of Vestibular Disorders (ICVD). Since then, numerous publications providing consensus-driven diagnostic criteria for vestibular symptoms, syndromes, and disorders have been published. Here, we reflect on the rationale for developing the ICVD as well as its subsequent achievements, challenges, and outlook. In this summary of the work of the ICVD to date, the authors will focus on practical aspects to help improve the utility and applicability of these diagnostic criteria moving forward.

AbstractPrior case reports have suggested that treating thoracic outlet syndrome (TOS) may relieve intractable migraine headaches, but there has been no case series large enough to show when underlying TOS should be suspected as a contributor to migraine burden. This observational followed by questionnaire study was performed in an outpatient neurology practice to identify clinical features of patients with migraine in which TOS contributed to migraine burden. We report the clinical features of 50 consecutive patients (48 women, 2 men, age = 43.9+/12.7 years) who were treated for chronic migraine and TOS (20 migraine with aura, 28 migraine without aura, two hemiplegic migraines). Headaches had become chronic within 1 year of onset in 21 patients (42%) with characteristics as follows (percentages are based on known data): greater severity ipsilateral to TOS limb pain (38/50=76%), presence of limb swelling (32/48=67%), and worsened by recumbency (32/38=84%). Thirty‐two patients eventually needed surgery, which included percutaneous transluminal venoplasty, 1st rib removal, scalenectomy, pectoralis minor tenotomy, and/or vein patching. The mean improvement of headaches on the treated side was 72 ± 26.7%; 12 patients experienced complete resolution of headaches after treatment of TOS (follow‐up 7.2 ± 5.2 months). Questionnaire responders reported significant reductions in headache days (18.3 ± 8.6 to 11.1 ± 10.8 days/month, p < 0.0016), severity (7.8+/2.5 to 5.4 ± 2.9, p < 0.00079), and need for emergency care (3.6 ± 4.0 to 0.71 ± 1.3 visits/year, p < 0.0029). Chronic migraines can be important manifestations of TOS. Early transition to a chronic state, lateralized limb pain, and headaches worsened by recumbency are clues to the contribution of TOS pathology. Addressing the TOS contribution to migraine can significantly reduce migraine headache burden.

We present diagnostic criteria for mal de débarquement syndrome (MdDS) for inclusion into the International Classification of Vestibular Disorders. The criteria include the following: 1] Non-spinning vertigo characterized by an oscillatory perception (‘rocking,’ ‘bobbing,’ or ‘swaying’) present continuously or for most of the day; 2] Onset occurs within 48 hours after the end of exposure to passive motion, 3] Symptoms temporarily reduce with exposure to passive motion (e.g. driving), and 4] Symptoms persist for >48 hours. MdDS may be designated as “in evolution,” if symptoms are ongoing but the observation period has been less than 1 month; “transient,” if symptoms resolve at or before 1 month and the observation period extends at least to the resolution point; or “persistent” if symptoms last for more than 1 month. Individuals with MdDS may develop co-existing symptoms of spatial disorientation, visual motion intolerance, fatigue, and exacerbation of headaches or anxiety. Features that distinguish MdDS from vestibular migraine, motion sickness, and persistent postural perceptual dizziness (PPPD) are reviewed. Motion-moderated oscillatory vertigo can also occur without a motion trigger, typically following another vestibular disorder, a medical illness, heightened psychological stress, or metabolic disturbance. Terminology for this non-motion triggered presentation has been varied as it has features of both MdDS and PPPD. Further research is needed into its phenomenological and biological relationship to MdDS, PPPD, and other vestibular disorders.