positional vertigo

The Cause of Dizziness is Often Misdiagnosed

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The Vestibular Disorders Association (VEDA) surveyed of hundreds of people suffering with a vestibular disorder and the results were published in the journal Otology & Neurotology in 2016. The results are as we would have predicted based on reported patient experiences prior to their initial visit to BalanceMD and are in keeping with many blogs and newsletter articles we have written on this subject over the past decade.

The purpose of the survey was to collect information on vestibular patients’ experiences with healthcare providers as they searched for answers to their problems – what they were told was causing their symptoms and what treatments they were given.

Some findings from the study are as follows:

Meniere’s disease was the top diagnosis given – 25% of those in the survey reported being diagnosed with Meniere’s disease. We know that Meniere’s actually represents a very small portion of vestibular disorder patients, less than 5%. On the other hand, only 18% of those in the study received the diagnosis of vestibular migraine, while nearly 50% actually have migraine as the underlying cause of their symptoms. Most experts place the Migraine:Meniere’s ratio 20-30:1. This highlights the popularity of the Meniere’s diagnosis and the under recognition of vestibular migraine.  Take home point: Meniere’s disease is a relatively rare condition and causes a specific type of hearing loss. Most who have been diagnosed with Meniere’s without hearing loss actually have a migraine syndrome as the underlying cause of their dizziness or vertigo spells.

Nearly half reported being treated with canalith repositioning maneuvers (such as the Epley maneuver) for BPPV, but only 15% reported being diagnosed with BPPV. In essence, over 30% of patients underwent an Epley maneuver, but never had BPPV. Take home point: BPPV is commonly over diagnosed. While there is no harm in doing an Epley maneuver, treating for a condition that isn’t present doesn’t work and appropriate treatment is delayed while the Epley maneuver is repeated unsuccessfully over weeks or months. There are several known types of BPPV amenable to immediate cure with a unique canalith repositioning maneuver over 90% of the time.

Close to 9% were diagnosed with bilateral vestibular hypofunction(weakness of both vestibular nerves). The actual number of patients with bilateral vestibular hypofunction is < 1%. The reason for this large discrepancy is that most facilities offering vestibular testing do not have a rotary chair. The diagnosis of “bilateral vestibular hypofunction” likely comes from weak caloric (air blown in the ears to induce nystagmus) responses in both ears. The best way to confirm (or refute) bilaterally weak vestibular nerves is the rotary chair. With bilateral vestibular hypofunction, the rotary chair test will be markedly abnormal. Take home point: Unfortunately, most facilities who perform vestibular testing do not have a rotary chair and will mis-diagnose a significant number of patients they test.

At BalanceMD, we have the knowledge, technologically advanced vestibular system test equipment and experience to accurately diagnose and effectively treat dizziness and vertigo no matter what the cause. Call 888-888-DIZZY (3499) or visit our website for further information.

3PD is a New Name for a Common and Under Recognized Cause of Dizziness

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Very few physicians have ever heard of ‘3PD’, which stands for Persistent Postural-Perceptual Dizziness. 3PD is a new name for a medical condition formerly known as ‘phobic postural vertigo’ or ‘chronic subjective dizziness’. As the features, diagnostic criteria and treatment options of 3PD have been refined over the years, 3PD will appear for the first time in the ICD-11 (11th version of the International Classification of Diseases), being released in 2017. So, if you are a healthcare provider and have never heard of 3PD, this article offers the opportunity to be on the leading edge of being able to recognize this condition in your patients.  If you are someone who suffers from dizziness that no one has been able to treat effectively, see if the description of 3PD below resembles your symptoms.

What is 3PD? 3PD is a non-vertiginous (non-spinning), waxing-waning dizzinessand/or unsteadiness, persisting for at least 3 months, with symptoms present at least 15 days per month, but typically daily. 3PD often follows a separate triggering event (vestibular neuritis, vestibular migraine, Meniere’s, head injury) that caused dizziness, vertigo or unsteadiness. With the anxiety or worry over an underlying sinister cause (i.e., tumor) of these dizzy symptoms or with the anticipation of having another vestibular attack, symptoms of 3PD develop.

What are the symptoms of 3PD? The symptoms of 3PD include dizziness and /or unsteadiness, worse when upright, head or body in motion, and in visually busy environments, becoming worse later in the day. Worsening of symptoms in grocery or large stores, when reading, scrolling on the computer or cell phone, and with exposure to complex patterns on carpeting, wallpaper or clothing, is common. Fatigue and trouble concentrating may develop.  The dizziness and/or unsteadiness becomes intrusive and the symptoms of 3PD have been called elsewhere (www.neurosymptoms.org) the “balance equivalent of tinnitus”.

How is 3PD treated? Once other causes are ruled out with appropriate vestibular function and/or other diagnostic testing, a combination of medications, such as benzodiazepines and SSRIs, and vestibular rehabilitation therapy is often effective. With significant underlying anxiety, cognitive behavioral therapy may also be helpful.

Meclizine Has Limited Use for Dizziness

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meclizineAntivert (meclizine) is one of the most popular and commonly prescribed medications for dizziness. However, there is no scientific evidence supporting it’s benefit and in fact, we now have evidence against it’s use, especially long-term use.

Meclizine is an antihistamine with anticholinergic, central nervous system and labyrinth (inner ear) depressant effects, so meclizine may cause drowsiness, confusion, memory impairment, and slow reaction time.

While migraine is the most common (and most under recognized) cause of dizziness, making up approximately 60% of all dizzy patients, Benign Paroxysmal Positional Vertigo (BPPV – aka the “crystal” problem) is second, making up about 15%. In neither condition is meclizine indicated. Meclizine would have minimal, if any benefit for migraine and may help blunt the vertigo associated with BPPV, but we are now able to instantly cure those suffering from BPPV, so why use meclizine at all?

Meclizine may be helpful short term in acute vestibular disfunction (sudden onset of vertigo), such as in vestibular neuritis (without hearing loss) or labyrinthitis (with hearing loss), an attack of Meniere’s, or to reduce motion sickness during travel. When used for these conditions or situations, only a short course, perhaps 3-7 days, should be prescribed.

Chronic use of meclizine is never indicated. Use of meclizine in the elderly, especially in the setting of peripheral neuropathy and/or vision loss from cataract, glaucoma or macular degeneration, may cause more imbalance and lead to painful falls. Chronic use of meclizine following vestibular nerve damage (such as with vestibular neuritis or labyrinthitis, trauma, or Meniere’s) will actually prevent the brain from adjusting and will reduce the effectiveness of vestibular rehabilitation therapy (a specialized form of physical therapy).

If you know of anyone who takes meclizine on a regular basis, please let them know there likely is a better treatment option available. As we are now better able determine the underlying cause of dizziness and vertigo, we have also developed more effective, targeted treatments.

Vertigo is a Symptom, NOT a Diagnosis

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vertigo girlWhen many patients arrive at our medical clinic, BalanceMD, they report that they were diagnosed with “vertigo”.  Vertigo is defined as the sensation a person has that they or objects around them are moving when they are not.  There are many medical conditions that might include vertigo as a symptom, most commonly migraine, benign paroxysmal positional vertigo (BPPV), vestibular neuritis or labyrinthitis, and Meniere’s disease.

Vertigo is a symptom, not a diagnosis, much in the same way that chest pain is a symptom, not a diagnosis.  There are many things that might cause chest pain, such as a heart attack, pneumonia, or a broken rib.  As it is important to determine the underlying cause of chest pain, it is also important to determine the underlying cause of vertigo.

While there are many conditions that might cause vertigo, there are only a handful that present most commonly and are listed above.  Differentiating between these conditions is best accomplished with a detailed clinical history, physical exam, and when needed, vestibular function testing and an audiogram (hearing test).  While migraine is the most common cause of recurrent spells of vertigo, BPPV is a vertigo-causing condition which can be quickly identified and cured.  Typical symptoms of BPPV include brief vertigo often lasting 10-15 seconds and triggered by lying back or sitting up in bed, rolling over in bed, and looking up or down.  Benign Paroxysmal Positional Vertigo is easy to evaluate and to treat.  If BPPV is not present, then vestibular function testing is typically necessary to evaluate for other inner ear or brain-related causes of vertigo.

Vestibular function testing is the test of choice in the identification of an underlying cause for vertigo.  This type of testing analyzes both inner ear and brain function associated with vertigo.  Vestibular function testing includes Videonystagmography (VNG), rotational chair, Vestibular Evoked Myogenic Potential (VEMP) and an audiogram.

Once the underlying cause for dizziness or vertigo is determined, a targeted treatment can be administered.  Because of advancements in our knowledge and technology over the past 20-25 years, we are much better able to arrive at a precise diagnosis.  We now know that while meclizine (Antivert), a commonly prescribed medication for those suffering with vertigo, may reduce vertigo symptoms for some conditions, it does not fix the underly problem causing vertigo.  Those who have been given meclizine (Antivert) for treatment of the symptom of vertigo and continue to suffer with vertigo should seek an evaluation from a specialist who is able to arrive at a diagnosis for the cause of vertigo and administer the most appropriate treatment and/or cure.

Vertigo Cure

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There are many causes of dizziness and vertigo that we are now able to recognize and treat. One common type of vertigo, known as BPPV (Benign Paroxysmal Positional Vertigo), aka “the crystal problem”, can be cured with a procedure known as a CRM (Canalith Repositioning Maneuver). Symptoms of BPPVinclude brief vertigo, lasting 10-15 seconds, brought on by lying back or getting up from bed, rolling over in bed, looking up or down. It is important to identify which type of BPPV is present, as we now know multiple types of BPPV exist. With the appropriate CRM, success in treating BPPV is nearly 100%. We should no longer be using medications, such as meclizine, or habituation exercises (Brandt-Daroff or Cawthorne-Cooksey) to treat BPPV. Click here to view a video of the most common type of BPPV, posterior semicircular canal BPPV.

Unfortunately, BPPV has become a well known entity over the years and is now over diagnosed.  Treatment with a CRM in someone who does not have BPPV will not work.  So, if you have been told that you have BPPV, but your vertigo symptoms did not resolve after a correctly performed CRM, then BPPV may not be the correct diagnosis.