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PubMed1995

The spectrum of vertigo in children.

OBJECTIVE: To review the presentation, evaluation, and causes of vertigo in children. DESIGN: A retrospective review of children who presented with the chief complaint of vertigo. PATIENTS: Thirty-four children with a chief complaint of vertigo were seen in an ear, nose, and throat clinic during a 2 1/2-year period. OUTCOME MEASURES: Presenting symptoms, diagnostic tests, diagnoses established, and clinical course were evaluated. RESULTS: Otitis media, benign paroxysmal vertigo of childhood, and migraine accounted for the vertigo in 50% of the children. Audiometry, tympanometry, and electronystagmography were the most helpful diagnostic tests, with abnormal results in seven, seven, and six patients, respectively. Of the 19 patients with adequate follow-up, 15 (79%) were improved or asymptomatic at the time of their last visit. CONCLUSIONS: Peripheral causes of vertigo, eg, otitis media, were noted most commonly. Evaluation of vertigo should include a complete history and physical examination, an audiogram, and a tympanogram. In select cases, electronystagmography, electroencephalography, and scanning of the brain or temporal bone should be performed. A favorable outcome was noted in most cases.

Adolescent↗
PubMed2001

Familial benign recurrent vertigo.

Benign recurrent vertigo (BRV) has been previously linked to migraine but there have been no prior studies of families with BRV. We studied the families of 24 patients who presented to our clinic with BRV and who reported a family history of similar attacks of vertigo. All probands underwent diagnostic evaluation to exclude identifiable causes of recurrent vertigo and they completed a standardized medical questionnaire pertaining to episodic vertigo and the features of migraine. This questionnaire was also sent to all relatives of the probands who agreed to participate. Of 220 relatives who returned questionnaires, 37% reported BRV and 50% met the diagnostic criteria for migraine. By contrast, only one of 43 (2%) unrelated spouses reported BRV and 10 of 43 (23%) met the diagnostic criteria for migraine. More than two-thirds of relatives with BRV met the diagnostic criteria for migraine and the majority reported that they had a typical migraine headache with at least some of their episodes of vertigo. Both BRV and migraine showed a female preponderance (more than 2 to 1). Familial BRV seems to be a migraine syndrome, probably inherited in an autosomal dominant fashion with decreased penetrance in men. In the search for the causative gene, vertigo may be a more useful marker than migraine because recurrent vertigo is relatively rare in the general population whereas migraine is very common.

Adult↗
PubMed1987

Exercise treatment for paroxysmal positional vertigo: comparison of two types of exercises.

The use of exercises can be an excellent method for treating benign paroxysmal positional vertigo (BPPV). We compared the results obtained by a progressive training method, vestibular habituation training (VHT), with a brisk exercise method. While VHT can be applied in all kinds of "provoked" (positional) vertigo of peripheral origin, the brisk method can be used only in typical BPPV, provided the vertigo is unilaterally provoked. A series of patients with such typical "unilateral" cases were treated by the brisk method and were compared with a second series of identical cases treated by the VHT technique. The results after 1 week seemed to be different: with the brisk method 52% of the patients were free of vertigo, while only 32% with VHT were vertigo free. This difference is not statistically significant. However, those cases treated by VHT and still having vertigo after 1 week had a striking reduction in the severity of their vertigo, as estimated by the score-system used. In contrast, the scores were unchanged for those cases not responding to the brisk method. Continuation of treatment of these latter cases using VHT exercises showed that the final result after 6 weeks was equal for both groups.

Exercise Therapy↗
PubMed1996

Postmarketing study of the use of flunarizine in vestibular vertigo and in migraine.

OBJECTIVE: This international postmarketing observational study of flunarizine was designed to evaluate, in routine clinical practice, the risk/benefit ratio of flunarizine in its approved indications, namely prophylaxis of migraine and treatment of vertigo. Comparator drugs were propranolol in migraine and betahistine in vertigo. The study was carried out by 498 general practitioners in Belgium, The Netherlands and Germany, whose participation had been requested by mail. In total 3186 patients were entered: 1601 in the two migraine cohorts and 1585 in the two vertigo cohorts. RESULTS: In the migraine study, treatment results with propranolol tended to be somewhat better than those with flunarizine, but a selection bias cannot be excluded. There was no clear difference regarding efficacy between flunarizine and betahistine in the vertigo study. The safety evaluation focused on extrapyramidal symptoms (EPS) and depression. Overall, EPS were noted in only four patients, two in the vertigo-betahistine and two in the migraine-flunarizine cohort. A total of 70 patients developed depressive symptoms (34 in the flunarizine and 24 in the propranolol migraine cohorts, but only 7 in the flunarizine and 5 in the betahistine vertigo cohorts). Patients with migraine were clearly more prone to depression than patients with vertigo, regardless of their treatment. Additional risk factors for depression were a history of depression, and, in the migraine flunarizine cohort, a high number of previous migraine treatments.

Basal Ganglia Diseases↗
PubMed2005

Benign paroxysmal positional vertigo and post-treatment quality of life.

Benign paroxysmal positional vertigo is probably the most common cause of vertigo. It is characterized by acute short-lived episodes of severe vertigo in association with change in the position of the head. This condition is benign, and after the repositioning procedure, the cure rate is between 70 to 80%. Numerous studies describe the association between vertigo and social handicap and emotional disturbance. In our study, we report for the first time the level of anxiety and social consequences, tested with the Hamilton anxiety scale and vertigo handicap questionnaire, in a group of patients who had suffered only from positional vertigo and were clinically cured when the questionnaires and test were administered. The important role played by psychological factors in maintaining or increasing the social consequences and perception of vertigo is revealed in this study.

Adult↗
PubMed2004

Investigating the causes of vertigo in breast cancer survivors.

The vertigo symptom in breast cancer survivors has rarely been mentioned. The aim of this study was to investigate the causes of vertigo in breast cancer survivors with vertigo. From May 1997 to April 2003, 36 consecutive female breast cancer survivors with vertigo underwent a battery of tests including physical examination, neurological examination, serum lipid profile, plain chest radiograph, whole body bone scan, liver sonography, audiometry, electronystagmography (ENG) and MRI scan. Based on these tests, the causes of vertigo were attributed to peripheral labyrinthine origin in 14 patients (39%) and central origin in 22 patients (61%) consisting of 11 cases of vascular insufficiency, eight of hyperlipidemia and three of posterior fossa metastases (8%). The latter included one case of cerebellopontine angle and two of cerebellum, accompanied by extracranial systemic metastases, e.g., of the lung, bone or liver. In conclusion, vertigo in breast cancer survivors warrants concern, especially in those with extra-cranial systemic metastasis accompanied by headache. In addition to 8% occurrence of posterior fossa metastasis, other possible causes for vertigo in breast cancer survivors consist of vascular insufficiency, hyperlipidemia and labyrinthine lesion.

Adult↗
PubMed2004

Neuroradiological features of vertigo.

The diagnostic pathway in a patient with vertigo starts with the accurate evaluation of medical history followed by a general physical and neurological examination. This step can often lead to the identification of the correct cause of the disease or, at least, to a distinction between peripheral and central vertigo. Neuroradiological investigations have to be considered as elective diagnostic procedures and include: computed tomography (CT), magnetic resonance (MR), MR angiography (MRA), angiography. For the diagnosis of peripheral vertigo, benign paroxysmal positional vertigo, labyrinthitis, Meniere disease, perilymphatic fistula, local trauma, toxic labyrinthitis, acute otitis media and chronic middle ear effusion,the role of imaging techniques is controversial. CT and MR are performed to rule out other pathologies and to confirm the diagnosis. Increased resolution and application of special MR sequences enhancing the intralabyrinthine fluids have enabled more detailed analysis of labyrinthine structures and pathology. Both T2 and T1 contrast sequences are necessary. A high resolution CT study is required when otitis media is suspected and in the follow-up of post-traumatic vertigo. The causes of central vertigo are numerous and include: vertebro-basilar circulation vascular events, multiple sclerosis (MS), migraine-associated vertigo, cerebellar and brainstem tumors, CNS infections. Among them cerebrovascular ischemia and multiple sclerosis are the most frequent. In these situations imaging studies become mandatory. CT can diagnose most cerebellar hemorrhages and some cerebellar and brainstem acute ischemia, enhanced MR has proved to be the most sensitive tool to detect posterior fossa lesion. Diffusion-weighted MR can reveal acute ischemic changes before routine MR. There has been evidence that MR angiography, providing angiogram-like images of the intracranial vessels may sometimes avoid invasive angiography. MRA resolution is not as good as traditional angiography and may also be compromised by movements and other artifacts. Selective angiography of the posterior circulation is often indicated for therapeutic decisions.

Brain↗
PubMed2003

[Non-benign paroxysmal positional vertigo].

Positional vertigo is a frequent clinical manifestation of vertigo of very different etiologies, being the benign paroxystic positional vertigo (BPPV) the most frequent one of them, representing in some series even the most found etiology of peripheral vertigo. Usually of severe entities, positional vertigo may appear in the context of severe entities and of difficult diagnosis. In these cases, the bearing of the symptoms in spite of the repositioning manoeuvers, the association with otological or neurological symptoms, and the atypical nystagmus evoked by Dix-Hallpike manoeuver, must take the otolaryngologist to suspect of a feasible non benign pathology. We report a case of positional paroxysmal vertigo caused by an intracranial tumour and we review the clinical signs that shoved help us to suspect of non benign pathologies that can mimic a positional vertigo.

Female↗
PubMed1998

Differentiating between peripheral and central causes of vertigo.

The history usually provides the key information for distinguishing between peripheral and central causes of vertigo. Probably the only central lesion that could masquerade as a peripheral vestibular lesion is cerebellar infarction because vertigo and severe imbalance may be the only presenting features. MRI is indicated in any patient with acute vertigo and profound imbalance suspected to be the result of cerebellar infarct or hemorrhage. Patients with chronic recurrent attacks of vertigo often have normal examination results, including normal vestibular function in between attacks. The duration of attacks is most helpful in distinguishing between central and peripheral causes; vertigo associated with vertebrobasilar insufficiency typically lasts minutes, whereas peripheral inner ear causes of recurrent vertigo typically last hours. Positional vertigo nearly always is a benign condition that can be cured easily at the bedside, but in rare cases it can be a symptom of a central lesion, particularly one near the fourth ventricle. Central positional nystagmus is nearly always purely vertical (either upbeating or downbeating), and there are usually associated neurologic findings.

Acute Disease↗
PubMedDate not supplied

Background and history of the interface between anxiety and vertigo.

The comorbidity of vertigo and anxiety has been an integral component of the medical literature since antiquity. In the works of Plato, the same terms were used in the context of vertigo, inebriation, height vertigo, disorientation, and mental confusion. In classical medicine, vertigo had the ambiguous status of being both a disease per se and a symptom of other diseases such as hypochondriacal melancholy. Further, two etiologies were described for vertigo: an origin in the head (brain) and an origin in the hypochondria (abdominal viscera). In the course of the development of a detailed neurologic taxonomy of vertigo in the latter half of the nineteenth century, a debate ensued whether agoraphobia was a form of vertigo or a distinct psychiatric condition. Elucidation of this forgotten debate, within its historical context, provides insights into the recent rediscovery of the balance-anxiety interface.

Agoraphobia↗
PubMed1999

The effectiveness of piracetam in vertigo.

Vertigo is a sensation of altered orientation in space and may be defined as an illusion of movement. It is a subjective symptom and therefore difficult to assess. Examination and diagnosis remain difficult. Although treatment should be directed at the underlying cause or disorder, the origin of vertigo is frequently unknown or untreatable. Pharmacotherapy is required for symptomatic treatment. Piracetam has been shown to be effective in vertigo of both central and peripheral origin. It is thought to act on vestibular and oculomotor nuclei in the brain stem and thus on the central control of balance enhancing mechanisms of compensation and habituation. This review of double-blind trials shows that piracetam alleviates vertigo after head injury, vertigo of central origin as, for example, in vertebrobasilar insufficiency and in peripheral vestibular disorders, especially in middle-aged and elderly subjects. Piracetam decreases the frequency but probably not the severity of exacerbations in patients with chronic or recurrent vertigo. The usual dosage of piracetam in vertigo is 2.4-4.8 g daily. Tolerability of piracetam is good and adverse effects have been mild and infrequent.

Controlled Clinical Trials as Topic↗
PubMed2003

Increased independence and decreased vertigo after vestibular rehabilitation.

OBJECTIVE: We sought to determine the effectiveness in decreasing some symptoms, such as vertigo, and increasing performance of daily life skills after vestibular rehabilitation. STUDY DESIGN AND SETTING: Patients who had chronic vertigo due to peripheral vestibular impairments were seen at a tertiary care center. They were referred for vestibular rehabilitation and were assessed on vertigo intensity and frequency with the use of the Vertigo Symptom Scale, the Vertigo Handicap Questionnaire, the Vestibular Disorders Activities of Daily Living Scale, and the Dizziness Handicap Inventory. They were then randomly assigned to 1 of 3 home program treatment groups. RESULTS: Vertigo decreased and independence in activities of daily living improved significantly. Improvement was not affected by age, gender, or history of vertigo. CONCLUSION: For many patients a simple home program of vestibular habituation head movement exercises is related to reduction in symptoms and increasing independence in activities of daily living.

Activities of Daily Living↗
PubMed2006

Analysis of the vestibulo-ocular reflex time constant in patients with benign recurrent vertigo associated with head-shaking nystagmus.

CONCLUSIONS: When considering benign recurrent vertigo and a similar peripheral vestibular deficiency, the asymmetry of the vestibulo-ocular reflex (VOR) time constant (Tc) is lower in those patients with paretic head-shaking nystagmus (HSN) than in those with reversed HSN or without HSN. OBJECTIVE: To determine whether the existence of HSN is related to the time constant of the VOR in patients with benign recurrent vertigo (BRV). PATIENTS AND METHODS: This was a prospective study conducted at a tertiary care center in which patients were subjected to the head-shaking test, the caloric test and rotatory chair impulsive test on the same day. The clinical features of the disease analyzed were the disease duration, frequency of vertigo spells, time since the last vertigo spell and the existence of migraine. The results of the head-shaking test were considered positive when nystagmus appeared after head-shaking had ended. Two groups of patients were established on the basis of these results and the group that displayed HSN was divided according to the direction of nystagmus. In the impulsive test, the time constant of the VOR after ipsilesional and contralesional acceleration was analyzed, as was the symmetry of the response. The differences in the means were calculated. RESULTS: BRV was diagnosed in 25% of patients suffering recurrent spells of vertigo, of which 33 patients were HSN- and 29 were HSN+. In the latter group, vestibular migraine was frequently observed (83% of the patients), the spells of vertigo were more frequent and the patients were seen closer to the previous spell of vertigo. No differences were observed in the Tc of the VOR between HSN+ and HSN- patients, although the asymmetry of this Tc was higher in HSN- patients than in HSN+ patients. Nevertheless, the differences observed were only significant between paretic and reversed HSN patients and paretic HSN patients and HSN- patients.

Caloric Tests↗
PubMed2002

Treatment of benign positional vertigo using the semont maneuver: efficacy in patients presenting without nystagmus.

OBJECTIVE: To evaluate and compare the efficacy of the Semont liberatory maneuver on "objective" benign paroxysmal positional vertigo (BPPV) defined as vertigo with geotropic nystagmus in Dix-Hallpike positioning versus "subjective" BPPV defined as vertigo without nystagmus in Dix-Hallpike positioning. STUDY DESIGN: Retrospective chart review. METHODS: One hundred sixty-two patients with positional vertigo during Dix- Hallpike positioning were identified. Patients were evaluated for the presence or absence of nystagmus. All patients underwent the Semont liberatory maneuver. The patient's condition at follow-up was documented at 3 weeks as complete, partial, or failure. Repeated procedures were performed if necessary. RESULTS: There were 127 cases of objective BPPV and 35 cases of subjective BPPV. Overall, 90% of all patients tested had significant improvement of their vertigo after 1.49 maneuvers on average. Improvement was seen in 91% of patients with objective BPPV after 1.59 maneuvers on average, compared with 86% in subjective BPPV after 1.13 maneuvers on average (chi2 test, not significant [P = .5]). Patients with a history of traumatic origin or cause had an overall success rate of 81% compared with 92% for nontraumatic causes or origins (chi2 test, not significant [P = .1]). Recurrences were seen in 29% of patients after a successful initial maneuver; however, 96% of these patients responded to further maneuvers. Four patients with persistent symptoms after conservative management underwent posterior semicircular canal occlusion with resolution of symptoms. CONCLUSION: The Semont liberatory maneuver provides relief of vertigo in patients with positional vertigo, even in patients without objective nystagmus.

Electronystagmography↗
PubMed2005

Episodic vertigo.

PURPOSE OF REVIEW: This review focuses on three neuro-otological syndromes, which are all marked by rapid scientific progress on the one hand but under-recognition or undertreatment on the other: benign paroxysmal positional vertigo and its variants, superior semicircular canal dehiscence syndrome, and migrainous vertigo. RECENT FINDINGS: The efficacy of Epley's maneuver for treatment of benign paroxysmal positional vertigo has been convincingly demonstrated by a meta-analysis of nine randomized controlled trials. Head vibration during Epley's procedure and keeping upright for 48 h after effective treatment do not improve the outcome. Superior canal dehiscence syndrome presents not only with sound and pressure-induced vertigo but also with conductive hearing loss at low frequencies. Migrainous vertigo may present not only with spontaneous attacks but also with positional vertigo or with chronic dizziness and imbalance. Vestibular rehabilitation has been proven to relieve chronic dizziness and visual vertigo. SUMMARY: Recent studies have eliminated several white spots on the neuro-otological map. However, many areas are still unexplored, particularly with regard to treatment of specific vestibular syndromes where randomized controlled trials are just at their beginning.

Humans↗
PubMed2003

Impact of treatment on health-related quality of life in patients with posterior canal benign paroxysmal positional vertigo.

OBJECTIVE: To determine the impact of the particle repositioning maneuver on posterior canal benign paroxysmal positional vertigo-related quality of life using the Medical Outcomes Study 36-Item Short Form Health Survey and the Dizziness Handicap Inventory Short Form. STUDY DESIGN: Prospective, consecutive new cases of posterior canal benign paroxysmal positional vertigo. SETTING: Ambulatory, primary referral hospital. PATIENTS: Forty individuals with posterior canal benign paroxysmal positional vertigo were investigated. The diagnosis was made on the basis of the history of recurrent sudden crisis of vertigo and positional-induced nystagmus during the Dix-Hallpike test. INTERVENTIONS: All patients were treated by a single particle repositioning maneuver, and relapses were investigated at Days 7 and 30 posttreatment. MAIN OUTCOME MEASURES: Percentage of patients with negative Dix-Hallpike test after treatment, scores obtained on the 36-Item Short Form Health Survey and Dizziness Handicap Inventory Short Form before and 30 days after treatment. RESULTS: DHT was found negative in 76% (28 of 37) individuals at 30 days. The eight scales of the 36-Item Short Form Health Survey had a good internal consistency reliability (Cronbach's alpha > 0.7) in patients with posterior canal benign paroxysmal positional vertigo. The average standardized score for each 36-Item Short Form Health Survey scale was compared with the reference population normative data, showing differences with norms for all scales, except for Vitality. After particle repositioning maneuver, patients scored closer to norms, and Social Function and Mental Health scores were significantly higher than the scores obtained before the particle repositioning maneuver (p < 0.05). Dizziness Handicap Inventory Short Form total score significantly decreased from 18.05 +/- 9.91 (mean +/- standard deviation) at the first day to 9.54 +/- 9.94 at 30 days (p < 0.001). All 36-Item Short Form Health Survey scale scores were correlated significantly with Dizziness Handicap Inventory Short Form total scores at 30 days after treatment. CONCLUSIONS: Posterior canal benign paroxysmal positional vertigo has a significant impact on health-related quality of life, and patients experienced a decrease in quality of life as compared with norms. The particle repositioning maneuver improves health-related quality of life in posterior canal benign paroxysmal positional vertigo.

Adult↗
PubMed2003

Bedside diagnosis of vertigo: value of the history and neurological examination.

Vertigo is caused by disturbance of the input or central processing of sensory signals from the vestibular apparatus that provide information regarding the position of the body in space. It is caused either by asymmetric disruption of sensory input from the vestibular organs or asymmetric integration of vestibular input into the central nervous system. Vertigo is readily differentiated from other causes of dizziness by a sensation of motion. A crucial aspect of the management of the emergency department patient with vertigo is the differentiation of vertigo associated with acute stroke syndromes from vertigo due to peripheral causes. Routine computerized axial tomography imaging is insensitive for posterior circulation strokes, so for emergency physicians, the history and neurological examination remain the most useful diagnostic tools. This article emphasizes the history and physical examination in the localization of the lesion in patients with vertigo and offers a rational basis for decisions regarding the need for special neurological imaging and consultation. It also emphasizes subtle findings that may prevent the erroneous diagnosis of peripheral vertigo in the presence of an acute stroke syndrome.

Dizziness↗
PubMedDate not supplied

The mechanism of physiological height vertigo. I. Theoretical approach and psychophysics.

A theory is presented supporting a geometrical explanation of physiological height vertigo as a 'distance vertigo' created by visual destabilization of posture when the distance between the observer and visible stationary contrasts becomes critically large. Though height vertigo is generally regarded as a psychopathological process, we hypothesize that it might instead result from an intersensory mismatch when visual information is at variance with vestibular and proprioceptive inputs. Psychophysical experiments confirming the hypothesis revealed that: 1) height vertigo is clearly related to body position, being the greatest in the upright stance; 2) it is the eye-object distance rather than the direction of gaze which is critical; 3) there is a saturation of height vertigo magnitude. Subjective vertigo increases with increasing altitude only below 20 metres. Physiological 'distance vertigo' must be distinguished from psychological 'acrophobia'. Its postural consequences may be ameliorated by strategies gleaned from knowledge of its mechanism such as providing nearby stationary contrasts in the peripheral visual field.

Adult↗