Vestibular Migraine — MCQs
A 35-year-old woman presents with a persistent, throbbing headache on one side of her head, associated with nausea and sensitivity to light. What is the most likely diagnosis?
Drugs used in management of migraine include the following except?
Migraine is due to
Triad of Meniere’s disease includes all except?
A 25-year-old woman presents with episodes of dizziness, tinnitus, and hearing loss in the right ear. What is the most likely diagnosis?
A 65-year-old woman complains of recurrent episodes of sudden-onset dizziness and nausea. She notices an abrupt onset of a spinning sensation when rolling over or sitting up in bed. The symptoms last for 30 seconds and then completely resolve. She has no hearing change or other neurologic symptoms, and her physical examination is completely normal. A Dix-Hallpike maneuver reproduces her symptoms. Which of the following findings on vestibular testing favors the diagnosis of benign paroxysmal positional vertigo (BPPV) over central positional vertigo?
Differential diagnosis of Meniere's disease includes all except -
A 27-year-old patient with a chief complaint of mild vertigo of 3-month duration is seen by a neurologist. Examination reveals a positional (horizontal and vertical) nystagmus that is bidirectional, and the patient reports the absence of tinnitus. Which of the following is the most likely etiology of the vertigo?
In a patient with right vestibular neuronitis, what will be the finding on the head impulse test?
Vestibular evoked myogenic potential (VEMP) is a tool for evaluating which of the following?
Vestibular Migraine Indian Medical PG Practice Questions and MCQs
Question 1: A 35-year-old woman presents with a persistent, throbbing headache on one side of her head, associated with nausea and sensitivity to light. What is the most likely diagnosis?
- A. Cluster headache
- B. Tension headache
- C. Sinusitis
- D. Migraine (Correct Answer)
Explanation: ***Migraine*** - Migraines are characterized by **unilateral, throbbing headaches** associated with **nausea, vomiting**, and **sensitivity to light (photophobia)** and sound (phonophobia) [1]. - The patient's presentation perfectly aligns with the classic symptoms of a migraine attack [1]. *Cluster headache* - Cluster headaches are characterized by **severe, unilateral pain**, but they are typically **periorbital or temporal** and associated with **autonomic symptoms** such as lacrimation, rhinorrhea, ptosis, and miosis [1]. - Unlike migraines, they tend to occur in clusters over several weeks or months, followed by a period of remission. *Tension headache* - Tension headaches are usually described as a **dull, aching pain** or a **tight band around the head**, often bilateral, and are typically **not associated with nausea, vomiting, or photophobia** [1]. - They are generally less severe and do not worsen with physical activity. *Sinusitis* - Sinusitis can cause headache, but it is typically accompanied by **facial pressure or pain**, nasal congestion, colored discharge, and sometimes fever. - The pain is usually localized to the frontal, maxillary, or ethmoid sinuses and is not typically throbbing or associated with photophobia and nausea to the extent seen in migraines.
Question 2: Drugs used in management of migraine include the following except?
- A. Topiramate
- B. Valproate
- C. Ethosuximide (Correct Answer)
- D. Verapamil
Explanation: ***Ethosuximide*** - **Ethosuximide** is an anti-epileptic drug primarily used to treat **absence seizures** by blocking T-type calcium channels [1]. - It has no established role in the **acute** or **prophylactic** management of migraine headaches. *Topiramate* - **Topiramate** is an anti-epileptic drug that is also approved for **migraine prophylaxis**. - Its mechanism of action in migraine includes modulating **GABA receptors**, blocking **voltage-sensitive sodium channels**, and inhibiting **carbonic anhydrase** [2]. *Valproate* - **Valproate** (valproic acid) is an anti-epileptic drug and mood stabilizer commonly used for **migraine prevention**. - Its migraine prophylactic effect is believed to involve increasing **GABA levels** and modulating **neurotransmitter release** [1]. *Verapamil* - **Verapamil** is a **calcium channel blocker** sometimes used off-label for **migraine prophylaxis**, particularly in cases of difficult-to-treat migraines or specific subtypes like **hemiplegic migraine**. - It works by reducing cerebral vasospasm and stabilizing neuronal membranes.
Question 3: Migraine is due to
- A. Constriction of cranial arteries
- B. Dilatation of cranial arteries
- C. Meningeal inflammation
- D. Cortical spreading depression (Correct Answer)
Explanation: ***Cortical spreading depression*** - **Cortical spreading depression (CSD)** is a wave of neuronal and glial depolarization that propagates across the cerebral cortex, which is now considered the most likely primary event triggering a migraine attack, particularly with aura [1]. - CSD leads to a complex cascade of events, including changes in cerebral blood flow, activation of the **trigeminal nervous system**, and the release of inflammatory mediators, all contributing to the headache and associated symptoms of migraine [1]. *Constriction of cranial arteries* - While **vasoconstriction** might occur in the **prodromal phase** or during the aura of migraine, it's not the primary cause of the headache itself. - The classic vascular theory of migraine, which posited vasoconstriction followed by vasodilation, has largely been refined by more comprehensive neurovascular models. *Dilatation of cranial arteries* - **Vasodilation** of meningeal and other cranial arteries is indeed a feature of the migraine headache phase, contributing to the painful throbbing sensation [1]. - However, this is largely considered a secondary event, a consequence of the activation of the **trigeminal-vascular system** triggered by upstream cortical events like CSD, rather than the initial cause of the migraine [1]. *Meningeal inflammation* - While activation of the **trigeminal nervous system** during a migraine attack does lead to the release of neuropeptides (e.g., **CGRP**, substance P) that can cause **neurogenic inflammation** in the meninges, this is a secondary phenomenon. - This **sterile inflammation** contributes to the pain but is not the initial trigger or *sine qua non* of a migraine attack.
Question 4: Triad of Meniere’s disease includes all except?
- A. Tinnitus
- B. Vertigo
- C. Migraine (Correct Answer)
- D. Hearing loss
Explanation: ***Migraine*** - **Migraine** is not considered part of the classic triad of Meniere's disease. While some patients with Meniere's may experience migraines, it is not a diagnostic criterion. - The core symptoms of Meniere's disease relate specifically to inner ear dysfunction and are distinct from primary headache disorders. *Tinnitus* - **Tinnitus**, often described as ringing, buzzing, or roaring in the ear, is a hallmark symptom and a key component of the Meniere's disease triad. - It usually fluctuates in intensity and can precede or coincide with vertigo attacks. *Vertigo* - **Vertigo**, characterized by sudden, severe spinning sensations, is the most debilitating symptom and an essential part of the Meniere's triad. - These episodes can last from minutes to hours and are often accompanied by nausea and vomiting. *Hearing loss* - **Hearing loss**, typically fluctuating and affecting low frequencies initially, is a crucial diagnostic criterion and part of the Meniere's triad. - The hearing loss tends to progress over time, often becoming more permanent and affecting a broader range of frequencies.
Question 5: A 25-year-old woman presents with episodes of dizziness, tinnitus, and hearing loss in the right ear. What is the most likely diagnosis?
- A. Labyrinthitis
- B. Ménière's disease (Correct Answer)
- C. Acoustic neuroma
- D. Benign paroxysmal positional vertigo
Explanation: ***Ménière's disease*** - This condition is characterized by a classic triad of **episodic vertigo (dizziness)**, fluctuating **sensorineural hearing loss**, and **tinnitus**, often accompanied by aural fullness, typically affecting one ear. - The symptoms arise from an accumulation of **endolymph** in the inner ear, leading to increased pressure and dysfunction. *Labyrinthitis* - **Labyrinthitis** is an inflammation of the inner ear, usually viral, causing sudden, severe **vertigo** potentially with hearing loss and tinnitus. - Unlike Meniere's disease, **hearing loss** and **tinnitus** in labyrinthitis are usually constant rather than episodic or fluctuating. *Acoustic neuroma* - An **acoustic neuroma** (vestibular schwannoma) is a benign tumor on the eighth cranial nerve, often causing **gradual, progressive unilateral hearing loss**, tinnitus, and **balance issues**, but typically not episodic severe dizziness. - While it can cause hearing loss and tinnitus, the **episodic nature of vertigo** is less common than in Ménière's disease. *Benign paroxysmal positional vertigo* - **BPPV** is characterized by sudden, **brief episodes of vertigo** triggered by specific head movements, caused by dislodged **otoconia** in the semicircular canals. - Critically, BPPV does **not** typically cause associated **hearing loss or tinnitus**, which are prominent symptoms in the presented case.
Question 6: A 65-year-old woman complains of recurrent episodes of sudden-onset dizziness and nausea. She notices an abrupt onset of a spinning sensation when rolling over or sitting up in bed. The symptoms last for 30 seconds and then completely resolve. She has no hearing change or other neurologic symptoms, and her physical examination is completely normal. A Dix-Hallpike maneuver reproduces her symptoms. Which of the following findings on vestibular testing favors the diagnosis of benign paroxysmal positional vertigo (BPPV) over central positional vertigo?
- A. habituation occurs (Correct Answer)
- B. absence of a latency period
- C. moderate vertigo
- D. absence of fatigability
Explanation: The phenomenon of **habituation**, where symptoms lessen with repeated positional changes, is characteristic of **BPPV** due to canalith dissolution or movement away from the cupula. In central positional vertigo, habituation typically does not occur, and the nystagmus may be persistent. **BPPV** typically presents with a **latency period** of a few seconds (usually 2-20 seconds) between the provocative maneuver and the onset of nystagmus and vertigo. The absence of a latency period is a characteristic more consistent with **central positional vertigo**. The severity of vertigo (moderate vs. severe) is not a reliable differentiating factor between BPPV and central positional vertigo, as both can cause significant discomfort. While BPPV often causes **severe vertigo with nystagmus**, central causes can also present with varying intensities of dizziness. **Fatigability**, meaning the nystagmus and vertigo decrease in intensity with repeated maneuvers, is a hallmark of **BPPV**. The **absence of fatigability** suggests a central cause, where nystagmus often persists or even increases with repeated testing.
Question 7: Differential diagnosis of Meniere's disease includes all except -
- A. Acoustic neuroma
- B. Suppurative otitis media (Correct Answer)
- C. CNS disease
- D. Labyrinthitis
Explanation: ***Suppurative otitis media*** - **Suppurative otitis media** is an **infection of the middle ear** causing pus formation, earache, and hearing loss, which is distinctly different from the inner ear disorder seen in Meniere's disease. - Its clinical presentation, including visible **tympanic membrane perforation** and **otorrhea**, does not mimic the classic Meniere's triad of episodic vertigo, tinnitus, and fluctuating hearing loss. *Acoustic neuroma* - This is a **benign tumor** on the **vestibulocochlear nerve** that can cause progressive unilateral hearing loss, tinnitus, and balance issues, similar in some ways to Meniere's. - However, the hearing loss is typically **slowly progressive** and not fluctuating episodically like in Meniere's disease. *CNS disease* - Various **central nervous system (CNS) conditions**, such as **migraine-associated vertigo** or **vertebrobasilar insufficiency**, can present with dizziness, balance problems, and even tinnitus. - Unlike Meniere's, these conditions often have additional **neurological deficits** and typically lack the classic triad of episodic vertigo, fluctuating hearing loss, and aural fullness. *Labyrinthitis* - **Labyrinthitis** is an **inflammation of the inner ear** that causes sudden, severe vertigo, nausea, and hearing loss, which can initially resemble a Meniere's attack. - However, labyrinthitis is usually **self-limiting**, resolves over weeks, and does not involve the recurrent, fluctuating symptoms and aural fullness characteristic of Meniere's disease.
Question 8: A 27-year-old patient with a chief complaint of mild vertigo of 3-month duration is seen by a neurologist. Examination reveals a positional (horizontal and vertical) nystagmus that is bidirectional, and the patient reports the absence of tinnitus. Which of the following is the most likely etiology of the vertigo?
- A. Lesion of the flocculonodular lobe of the cerebellum (Correct Answer)
- B. Ménière’s syndrome
- C. Labyrinthitis
- D. Lesion of the spinocerebellum (affecting limb coordination)
Explanation: ### Lesion of the flocculonodular lobe of the cerebellum - **Bidirectional nystagmus**, especially when it's positional (horizontal and vertical) but not consistent with peripheral etiologies, strongly suggests a central lesion, such as one in the **flocculonodular lobe** [1]. - The absence of **tinnitus** and the chronicity of the mild vertigo further support a central rather than peripheral vestibular cause [1]. ### Labyrinthitis - **Labyrinthitis** is typically characterized by **unidirectional nystagmus** and a sudden onset of severe, often debilitating vertigo, which is not described here [1]. - It frequently involves associated symptoms like **hearing loss** and **tinnitus**, which are absent in this patient. ### Ménière’s syndrome - **Ménière’s syndrome** presents with episodic, intense vertigo accompanied by **tinnitus, hearing loss**, and a feeling of aural fullness, none of which are reported in this patient. - The nystagmus in Ménière's is typically **unidirectional** during acute attacks. ### Lesion of the spinocerebellum (affecting limb coordination) - A lesion of the **spinocerebellum** primarily affects **gait and limb coordination**, leading to **ataxia** and dysmetria, rather than isolated vertigo or nystagmus as the chief complaint [1]. - While cerebellar lesions can cause nystagmus, a lesion in the spinocerebellum would prominently feature motor incoordination symptoms not mentioned.
Question 9: In a patient with right vestibular neuronitis, what will be the finding on the head impulse test?
- A. Head turned to right, corrective saccade to the left (Correct Answer)
- B. Head turned to left, corrective saccade to the right
- C. Head turned to right, no corrective saccade
- D. Head turned to left, no corrective saccade
Explanation: ***Head turned to right, corrective saccade to the left*** - In **right vestibular neuronitis**, the right vestibular apparatus is impaired, affecting the **vestibulo-ocular reflex (VOR)** on that side. - During the head impulse test, when the head is rapidly turned **to the right** (toward the affected side), the impaired VOR cannot maintain eye fixation on the target. - The eyes initially move **with the head** (to the right), then a visible **corrective saccade** (catch-up saccade) brings them **back to the left** to refixate on the target. - This corrective saccade is the **hallmark positive finding** in head impulse test for right vestibular dysfunction. *Head turned to left, corrective saccade to the right* - This would indicate a **left vestibular lesion**, not right vestibular neuronitis. - When turning the head to the left with left vestibular dysfunction, a corrective saccade to the right would be observed. *Head turned to right, no corrective saccade* - This would indicate **normal VOR function** on the right side. - A normal response shows no corrective saccade because the eyes maintain fixation throughout the head turn. - This is the **opposite** of what is expected in right vestibular neuronitis. *Head turned to left, no corrective saccade* - This indicates normal VOR function on the left side. - In right vestibular neuronitis, turning the head to the left (away from the affected side) typically shows **normal VOR** with no corrective saccade needed.
Question 10: Vestibular evoked myogenic potential (VEMP) is a tool for evaluating which of the following?
- A. Superior vestibular nerve disorders
- B. Cochlear nerve lesions
- C. Auditory nerve function
- D. Inferior vestibular nerve disorders (Correct Answer)
Explanation: ***Inferior vestibular nerve disorders*** - **VEMP** uses **loud acoustic stimuli** or **bone vibration** to activate the **saccule**, with the response pathway: saccule → inferior vestibular nerve → vestibular nucleus → vestibulospinal tract → muscle response. - **Cervical VEMP (cVEMP)** is recorded from the **sternocleidomastoid muscle**, while **ocular VEMP (oVEMP)** is recorded from **extraocular muscles**; absent or delayed responses indicate **saccular or inferior vestibular nerve dysfunction**. *Superior vestibular nerve disorders* - The **superior vestibular nerve** innervates the **utricle** and **semicircular canals**, which are assessed by **head impulse test** and **caloric testing**, not VEMP. - **VEMP** is the only clinical test specifically assessing **otolith (saccule) function** and does not evaluate semicircular canal pathways. *Cochlear nerve lesions* - **Cochlear nerve** assessment requires **pure tone audiometry**, **auditory brainstem response (ABR)**, and **otoacoustic emissions**. - **VEMP** evaluates vestibular pathways through **muscle reflexes**, not auditory nerve conduction or cochlear function. *Auditory nerve function* - **VEMP** is a vestibular test that evaluates **otolith organs** and their neural pathways, not auditory function. - While VEMP uses **acoustic stimuli** to trigger the response, it measures **vestibulospinal or vestibulo-ocular reflexes**, not hearing or auditory nerve conduction.
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