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.
Feeling dizzy or having spells of vertigo (an illusory sense of motion usually described as ‘spinning’) can be quite troubling to most people. Of utmost concern is whether these symptoms represent something serious, such as a brain tumor. Rest assured, isolated symptoms of dizziness or vertigo are an extremely rare presenting sign of a brain tumor. To quote Arnold Schwarzenegger in ‘Kindergarten Cop’ (using his Austrian accent) “It’s not a tumor!”
Despite this, at least in the United States, it is the norm to proceed with a neuro-imaging study, such as CT or MRI, of the brain to “rule out” brain tumor, stroke, or multiple sclerosis (MS). There have been several studies concluding that doing CT and MRI scans for ‘dizziness’ or ‘vertigo’ in the absence of other neurologic signs or symptoms and in the absence of asymmetric hearing loss is not cost effective and rarely leads to a diagnosis.
Consider the following quote from Australian neuro-ophthalmologists who specialize in vestibular disorders:
“Balance disorders are common, while brain tumors are rare. An isolated balance disorder is thus rarely the presenting symptom of a brain tumor, and some physicians, particularly in countries infested with lawyers, worry about missing a brain tumor” – Hirose & Halmagyi, 1996
What country do you think they are referring to (“infested with lawyers”)?
On the other hand, vestibular function testing [which includes video-nystagmography (VNG), rotary chair, vestibular evoked myogenic potential (VEMP) and audiogram(hearing test)] assesses for both central (brain) and peripheral (inner ear) causes for dizziness and vertigo and can be quite helpful in localizing ‘where’, and then ‘what’ is causing the problem. Vestibular function testing has been demonstrated to be much more accurate and much more cost effective than MRI or laboratory tests in determining the cause of dizziness and vertigo.
‘Dizziness’ and ‘vertigo’ are symptoms, not diagnoses. Proper treatment of vestibular disorders is based on first determining the cause of dizziness or vertigo. Determining the cause of symptoms begins with a thorough history and physical examination followed by vestibular function testing in select patients.
When 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.
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.
In a 2011 survey by the Vestibular Disorders Association (VEDA), it was determined that those suffering from dizziness (the “dizzy” patient) were on average seen by 4-5 doctors before receiving the correct diagnosis. As is the case with any medical condition, without the correct diagnosis, the most appropriate treatment cannot be administered.
Symptoms of dizziness are typically subjective and an accurate diagnosis at first may not be straight forward. Many patients suffering from dizziness typically see several doctors and undergo multiple tests while accumulating large medical bills and no answers. The time “dizzy” patients spend in this process can be months to years and may result in painful fall-related injuries while seeking help from various healthcare practitioners.
“Dizzy” patients may initially be seen by their primary care physician or go to an urgent care facility or emergency room, then, as the potential underlying cause for dizziness can be diverse, referred to ENT (Ear, Nose and Throat – aka Otolaryngologist), a neurologist and/or cardiologist. Studies reveal that many undergo brain or sinus CT and/or MRI scans, carotid doppler studies, EEG, EKG, echocardiogram, tilt table testing, and blood tests, all of which have low yield in arriving at the correct diagnosis for most “dizzy” patients. Vestibular suppressant medications, such as meclizine, diazepam or promethazine, typically offer little relief and the majority of “dizzy” patients do not significantly benefit from PT (physical therapy).
The knowledge and technology we have available today in the diagnosis and treatment of the “dizzy” patient has advanced significantly and is different than what would have been considered standard of care just 20 years ago. At the initial visit to a physician experienced in vestibular disorders, the “dizzy”patient will be given the most likely diagnosis and a short list of differential diagnoses. Vestibular function testing and an audiogram (hearing test) are generally the most valuable tests to obtain for the “dizzy” patient, and will help confirm or refute the diagnosis suspected by clinical information obtained in the history and physical exam.
Arriving at the correct diagnosis is vitally important because effective treatment of “dizziness” depends on the diagnosis. One cause of dizziness requires a specific sequence of head movements which can result in an instant cure, another cause is treated by reducing dietary sodium and/or a diuretic medication, while the most common cause of dizziness improves or resolves with a migraine-preventative medication, and other causes benefit from a specialized form of PT (physical therapy) known as vestibular rehabilitation therapy.
Especially in this age of high deductible health insurance plans, patients are seeking the most expedient and accurate diagnoses and the most effective treatment in a cost-effective manner. With the advanced diagnostic and treatment capabilities available today, “dizzy” patients should no longer have to see 4-5 doctorsbefore receiving the correct diagnosis.