vestibular migraine

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.

BPPV is Over Diagnosed

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bppv-otoconia-cdWhat is BPPV?

BPPV (Benign Paroxysmal Positional Vertigo) is a common inner ear disorder that causes brief spells of vertigo (spinning sensation) triggered by a change in head position. For example, lying back or rolling over in bed, getting up from bed, looking up or down results in brief, 10-15 seconds of vertigo and usually no dizziness any other time. BPPV is caused by“crystals” normally present in one part of the inner ear, but become detached and displaced into another part of the inner ear where they cause vertigo with changes in head position. However, there are many patients diagnosed with BPPV who do not fit this description of symptoms or have a different cause of positional vertigo, yet are often diagnosed and unsuccessfully treated as though they had BPPV.

Why is BPPV Over-diagnosed?

BPPV has gained popularity as a diagnosis because it is a benign condition that causes vertigo and is readily diagnosed and immediately cured by a skilled healthcare provider. Patients often joke about “having a few loose rocks” in their head. BPPV is a common condition, but there are many more people diagnosed with BPPV than actually have BPPV.

How is BPPV Treated?

BPPV is treated by a “crystal repositioning maneuver” (CRM), which is designed to move the “crystals” by gravity back to where they originated, where they may be dissolved. The type of CRM utilized depends on the type of BPPV. For example, one form of BPPV is treated with a modified Epley or a Semont maneuver and another type with a Lempert roll. There is also a type of BPPV where the “crystals” are actually stuck to a membrane in the inner ear and is treated with a headshake of Gufoni maneuver. BPPV is no longer treated by the old fashioned Brandt-Daroff or Cawthorne-Cooksey exercises, or with medications, such as meclizine (Antivert). We are actually able to cure BPPV in one visit over 90% of the time with the appropriate CRM. Unfortunately, we see many patients incorrectly diagnosed with BPPV undergoing a modified Epley maneuver dozens of times unsuccessfully.

What else causes positional vertigo if it’s not BPPV?

Because migraine is the most common cause of dizziness/vertigo and can cause positional symptoms, the most common correct diagnosis in those mis-diagnosed with BPPV, is vestibular migraine. Other conditions which may cause positional dizziness include inner ear nerve weakness, blood pressure changes and even brain tumors. Obviously, it is very important to be certain of the cause of vertigo, as we don’t want to ineffectively treat for a condition that isn’t present and we don’t want to miss a more sinister cause.

Meniere’s Disease is Over Diagnosed

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Meniere’s disease is a disorder of the inner ear characterized by recurrent spells of vertigo (spinning sensation), hearing loss, tinnitus (ear noise) and a full feeling in the ear. The average age of onset of Meniere’s is around 50 and the underlying cause is unknown.

The inner ear has fluid-filled chambers and canals, which send information from the inner ear to the brain to interpret your body’s position, movement and to maintain balance. A Meniere’s “attack” occurs when the properties of the inner ear fluid become altered. The symptoms (below) begin suddenly and the severity of each spell varies.

 

Meniere's Dz

Symptoms

The symptoms of Meniere’s typically include recurrent vertigo spells lasting 20 minutes to several hours, low frequency (pitch) hearing loss, roaring tinnitus and a sense of fullness or pressure in the involved ear. Early on, hearing may improve between attacks but repeat attacks often lead to some degree of permanent hearing loss. Meniere’s generally affects only one ear, but may affect both ears in at least 20% of those affected.

Treatment

There is no cure for Meniere’s disease, but most will do well with some lifestyle changes and medication. Reducing sodium (salt) in the diet and the use of diuretics (water pills) may reduce vertigo symptoms and prevent recurrent attacks. Other factors that may influence Meniere’s attacks include alcohol, caffeine, smoking and stress. If symptoms are not adequately controlled by reduced salt intake, diuretic medication, and lifestyle changes, there are several surgical procedure options that may be effective in controlling symptoms.

Warning

Unfortunately, Meniere’s disease is a condition that is over-diagnosed, meaning that many are diagnosed with Meniere’s disease, but they don’t actually have it. If you or someone you know has been diagnosed with Meniere’s and do not have significant hearing loss in one ear and/or are under the age of 40, consider obtaining a second opinion. Most who are incorrectly diagnosed with Meniere’s are suffering from Vestibular Migraines and there are many effective treatment options available for Vestibular Migraine.

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.

Migraine is THE Most Common Cause of Dizziness

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What seems to be the most under-recognized, yet most common cause of dizziness or vertigo is not an inner ear condition at all – it is migraine. This condition is known as “vestibular migraine” or “migraine-associated dizziness” or “migrainous vertigo”. The main reason it seems to evade diagnosis is that many suffering from this condition are not having headaches at the time they are dizzy. In fact, many patients haven’t had a headache in years or even decades. Patients usually (but not always) have a history of what sounds like migraine headaches, but they will often refer to headaches as “sinus” headaches.

Symptoms of “vestibular migraine” are quite variable, being different from one patient to another and different within the same patient over time. Dizziness and/or vertigo may be reported with a duration of seconds to decades. Patients often have difficulty in describing their symptoms. Morning predominance of dizzy symptoms and visual motion sensitivity are typical. Visual motion sensitivity might include activities such as driving and shopping for items on shelves (especially in big box stores), or being bothered by patterns on clothing or carpeting. Light and/or noise sensitivity are only sometimes present.

Diagnosis of vestibular migraine includes ruling out other causes by vestibular function evaluation (Videonystagmography or VNG, Rotary Chair, Vestibular Evoked Myogenic Potential or VEMP, and an Audiogram). MRI and CT scans or blood tests are rarely necessary.

In the past, many patients suffering from spells of vertigo without hearing loss had been diagnosed with “Vestibular” Meniere’s. However, “Vestibular” Meniere’s is no longer considered a valid diagnosis. The vast majority of these patients were (and likely still are because low salt diet, diuretic, and/or inner ear surgery aren’t helpful treatments for migraine) suffering from “Vestibular” Migraine.

Treatment of vestibular migraine includes recognizing and avoiding trigger factors, and depending on frequency and/or duration of symptoms, preventative migraine medications. In some cases, in particular when motion sensitivity is prominent, a specialized form of physical therapy (PT) known a Vestibular Rehabilitation Therapy (VRT) can be helpful.