From the Guidelines
Fecal incontinence during a vestibular migraine episode should be managed with a focus on the underlying conditions, prioritizing the patient's quality of life and minimizing morbidity and mortality. When managing fecal incontinence with episode of vestibular migraine, it is crucial to consider the impact of Inflammatory Bowel Disease (IBD) on patients' lives, as discussed in the N-ECCO consensus statements 1. The immediate and long-term physical, social, and emotional impact of IBD, including patients' key concerns and the effect on Health-Related Quality of Life (HRQoL), should be taken into account [EL3] 1. Key points to consider include:
- The need to be near a toilet due to urgency and fear of losing bowel control
- The high prevalence of fecal incontinence in patients with IBD, which can be as high as 74% at some point in the disease course
- The psychological impact of IBD, including anxiety, depression, and distress, which can be addressed through routine screening and referral to specialist support services if necessary
- The importance of self-management and the use of appropriate tools to facilitate this, such as pelvic floor exercises and medication to control symptoms. Given the complexity of managing fecal incontinence during a vestibular migraine episode, a two-pronged approach addressing both conditions is recommended, with a focus on minimizing morbidity and mortality, and improving quality of life. This approach should include:
- Management of vestibular migraine symptoms, such as taking sumatriptan or preventative medications like propranolol or topiramate
- Management of fecal incontinence, such as starting with loperamide and implementing pelvic floor exercises
- Consideration of the connection between the two conditions, including the potential role of the autonomic nervous system in triggering autonomic instability affecting bowel control. It is essential to keep a symptom diary to track triggers for both conditions and to consult a neurologist and gastroenterologist for specialized evaluation if symptoms persist.
From the Research
Fecal Incontinence and Vestibular Migraine
- Fecal incontinence is a multifactorial disorder that imposes considerable social and economic burdens 2
- The current treatment options for fecal incontinence include conservative approaches, such as dietary modifications, medications, muscle-strengthening exercises, and biofeedback, which have been shown to provide short-term benefits 2
- Sacral nerve stimulation has shown reasonable short-term effectiveness and some complications in the treatment of fecal incontinence 2, 3
- Combination therapy with biofeedback, loperamide, and stool-bulking agents has been found to be effective for the treatment of fecal incontinence in women 4
- However, there is no direct evidence in the provided studies that links fecal incontinence with vestibular migraine, and therefore, the treatment options for fecal incontinence may not be directly applicable to episodes of vestibular migraine
Treatment Options for Fecal Incontinence
- Conservative measures, such as dietary modifications and biofeedback therapy, are modestly effective in the treatment of fecal incontinence 2, 4
- Invasive procedures, including sacral nerve stimulation, may be considered when conservative therapies are ineffective, but they are associated with complications and lack randomized, controlled trials 2, 3, 5
- Bulking agents may be an appropriate alternative therapy to consider before more aggressive therapies in patients who fail conservative therapies 2
- Pelvic floor muscle strengthening with or without biofeedback, devices placed anally or vaginally, and surgery, including sacral neurostimulation, anal sphincteroplasty, and colonic diversion, are also treatment options for fecal incontinence 6