A randomized double-blind, placebo-controlled, cross-over trial (Vestparoxy) of the treatment of vestibular paroxysmia with oxcarbazepine

Vestibular Paroxysmia with Neurovascular Cross Compression and Antiepileptic Drugs: A Systematic Review and Discussion of Physiopathology

Vestibular paroxysmia (VP) is a disabling medical condition characterized by a high recurrence rate of vertigo. VP is classically associated with the presence of contact between a vascular structure and the cochleovestibular nerve, a neurovascular cross compression (NVCC). Antiepileptic drugs are the first-line treatment for disabling symptoms. We conducted a systematic review to evaluate their efficacy in patients with VP, and whose imaging shows NVCC. All published studies in PubMed databases until October 2024 were included. A total of seven studies were selected. Carbamazepine and oxcarbazepine are by far the most widely used drugs, but there is still a lack of data showing the efficacy of antiepileptic drugs in a large sample of patients. This suggests that a future randomized controlled trial with a satisfactory sample size of VP patients with NVCC and comparing several drugs with neuroprotective properties is needed. Further, as imaging in some of the patients with obvious clinical signs does not always support this diagnosis, we discussed VP physiopathology and the different types of VP published in the literature, including those with no radiological support for NVCC.

Vestibular paroxysmia: a systematic review

The key symptoms of vestibular paroxysmia (VP) due to neurovascular cross-compression (classical VP) or compression of the eighth nerve by space-occupying cerebellar-pontine angle processes (secondary VP) are frequent short attacks of vertigo and dizziness with unsteadiness which last seconds to minutes. They can be accompanied by unilateral auditory symptoms such as tinnitus or hyperacusis. Head movements and hyperventilation can induce nystagmus and VP attacks that most often occur spontaneously. VP is diagnosed in 3% of patients in a tertiary vertigo care center and very rarely affects children. The mean age of first appearance is 47 to 51 years with equal sex distribution. A combination of high-resolution MRI sequences (with constructive interference in steady-state/fast imaging employing steady-state, 3D-CISS/ FIESTA) of the cerebello-pontine may support the diagnosis although the beneficial treatment with sodium channel blockers is the most reliable clinical sign for classical VP, secondary VP and idiopathic VP (without verification of a causative pathology). Because of the frequency, shortness, and audiovestibular symptomatology of the attacks, the differential diagnosis to other conditions such as paroxysmal brainstem attacks, vestibular epilepsy, rotational vertebral artery compression syndrome or "near"-narrowed internal auditory canal syndrome is only relevant in exceptional cases. However, imaging of the posterior fossa including the inner ear is mandatory to distinguish between classical, secondary and idiopathic VP forms. Randomized controlled trials for medical treatment are still needed. Practical therapy of choice is medical treatment with sodium channel blockers (carbamazepine, oxcarbazepine, lacosamide). A microsurgical decompression is effective in secondary VP but is the ultimate therapy in cases with classical or idiopathic VP when medication is not tolerated.

World-wide survey on the treatment of peripheral vestibular disorders

Objective

The aim of this world-wide survey was to evaluate the currently applied treatment options for the six most frequent peripheral vestibular disorders: benign paroxysmal positional vertigo (BPPV), acute unilateral vestibulopathy (AUVP)/vestibular neuritis, Menière's disease (MD), bilateral vestibulopathy (BVP), vestibular paroxysmia (VP) and superior canal dehiscence syndrome (SCDS).

Background

For the therapy of vestibular disorders, there are four treatment options: vestibular physical therapy (canalith repositioning maneuvers or balance training), pharmacotherapy, surgery, and psychotherapy. Since there are very few state-of-the-art RCTs, the treatment of vestibular disorders is so far not standardized and various methods are applied with heterogeneous efficacy.

Design/methods

A web-based standardized survey questionnaire on the treatment of the six most frequent peripheral vestibular disorders was used to collect data.

Results

234 replies from five continents, 47 countries, 162 cities and 188 centers were received: (% from all 234 replies; multiple answers possible): BPPV: posterior canal BPPV: 71% Epley, 40% Semont, and 12% others. Horizontal canal BPPV canalolithiasis: 58% Lempert (roll-over) maneuver, 33% Gufoni, 7% prolonged rest, and 9% others. Horizontal canal BPPV cupulolithiasis: 35% Gufoni, 27% Lempert (roll-over) maneuver, 9% Zuma, and 7% head shaking: AUVP: 79% pharmacotherapy, namely 47% glucocorticoids, 39% antiemetics, and 24% betahistine; 67% vestibular physical therapy. MD: 85% pharmacotherapy, namely 65% betahistine, 21% diuretics, 20% steroids, 16% antiemetics, 14% gentamicin; 37% surgery. VP: 65% pharmacotherapy, namely 57% anticonvulsants; 7% surgery. BVP: 77% vestibular physical therapy. SCDS: 50% surgery, namely 38.8% canal plugging, 23.3% capping and 15.5% resurfacing.

Conclusion

In this world-wide survey with 234 replies from 188 centers, widely heterogeneous applied treatment options were reported for the six most frequent peripheral vestibular disorders. This study shows in particular that certain drugs are often used despite low or very low evidence. Namely in AUVP, MD and VP well-designed controlled trials with clinically meaningful endpoints are needed.

Medical Management of the Near-Narrowed Internal Auditory Canal Pathology in the Adult Population: A Preliminary Study

Background/Objectives: Objective: To discuss therapeutic outcomes in patients with symptomatic near-narrow internal auditory canal (NNIAC). Methods: We retrospectively analyzed the records of 26 symptomatic patients diagnosed with NNIAC, who had been treated with anti-epileptic drugs. In addition to clinical and radiological data, we recorded I-III latencies of auditory brainstem responses prior to and after medical therapy. Results: Among a total of 48 patients with NNIAC, 26 patients were included. Oxcarbazepine, Gabapentin, and Lamotrigine were prescribed among 19 (73%) patients, 6 (23%) patients, and 1 patient (4%), respectively. After treatment, 24 (92.3%) patients described improvement of vestibular symptoms, and 16 (76.2%) reported improvement of auditory symptoms. After treatment with antiepileptic drugs, ipsilateral IPL I-III latencies decreased (less than 2.3 ms) in 16 (84.2%) patients (23 ears out of 42). Conclusions: A low dose of anti-epileptic monotherapy for NNIAC could be effective over the long term and is generally well-tolerated. Further studies are needed to provide more solid evidence of the efficacy and safety of anti-epileptic drugs on a larger number of patients with NNIAC.

[The six most frequent peripheral vestibular syndromes]

Three forms of peripheral vestibular disorders, each with its typical symptoms and clinical signs, can be differentiated functionally, anatomically and pathophysiologically: 1. inadequate unilateral paroxysmal stimulation or rarely inhibition of the peripheral vestibular system, e. g., BPPV, Menière's disease, vestibular paroxysmia or syndrome of the third mobile windows; 2. acute unilateral vestibulopathy leading to an acute vestibular tone imbalance manifesting as an acute peripheral vestibular syndrome; and 3. loss or impairment of function of the vestibular nerve and/or labyrinth: bilateral vestibulopathy. For all of these diseases, current diagnostic criteria by the Bárány-Society are available with a high clinical and scientific impact, also for clinical trials. The treatment depends on the underlying disease. It basically consists of 5 principles: 1. Explaining the symptoms and signs, pathophysiology, aetiology and treatment options to the patient; this is important for compliance, adherence and persistence. 2. Physical therapy: A) For BPPV specific liberatory maneuvers, depending on canal involved. Posterior canal: The new SémontPLUS maneuver is superior to the regular Sémont and Epley maneuvers; horizontal canal: the modified roll-maneuver; anterior canal the modified Yacovino-maneuver; 3. Symptomatic or causative drug therapy. There is still a deficit of placebo-controlled clinical trials so that the level of evidence for pharmacotherapy is most often low. 4. Surgery, mainly for the syndrome of the third mobile windows. 5. Psychotherapeutic measures for secondary functional dizziness.

Vestibular paroxysmia: Long-term clinical outcome after treatment

Objective

To study the long-term treatment outcome of vestibular paroxysmia (VP).

Study design

Retrospective study.

Setting

Tertiary referral hospital.

Methods

We analyzed records of 29 consecutive patients who were diagnosed with VP and who were treated with VP-specific anticonvulsants for at least 3 months. Patients were followed for a minimum of 6 months. We recorded and assessed starting and target dosage of medications, time to achieve adequate therapeutic response, adverse effects, and the rates of short-term and long-term remission without medication.

Results

All 29 patients were started on oxcarbazepine as first-line treatment, and 93.1% and 100% of patients reported good-to-excellent therapeutic response within 2 and 4 weeks, respectively. Three patients switched to other anticonvulsants at 3 months. At long-term follow-up (8–56 months), most (84.6%) oxcarbazepine-treated patients maintained good therapeutic response at doses between 300 and 600 mg/day. Eleven (37.9%) patients experienced complete remission without medication for more than 1 month, of which six (20.7%) had long-term remission off medication for more than 12 months. Nineteen (65.5%) patients had neurovascular compression (NVC) of vestibulocochlear nerve on MRI, but its presence or absence did not predict treatment response or remission.

Conclusion

Low-dose oxcarbazepine monotherapy for VP is effective over the long term and is generally well-tolerated. About 20% of patients with VP in our study had long-term remission off medication.

Case report: Bitter vertigo

Background

There are many causes of episodes of vertigo and very few causes of episodes of changes in taste, and the combination of the two is very rare. Here, we describe a patient with recurrent short episodes of vertigo in combination with simultaneous episodes of recurrent paroxysmal dysgeusia and altered feeling on the left side of face. The symptoms were caused by compression of the vestibulocochlear nerve and the facial nerve due to dolichoectasia of the basilar artery.

Methods

The patient was diagnosed in our routine clinical practice and underwent a complete neurological and neuro-otological examination, including video head impulse test, caloric irrigation, ocular and cervical vestibular evoked myogenic potentials, acoustic-evoked potentials, neuro-orthoptic examination, cranial MRI, and MR angiography. The patient was seen twice for follow-up.

Case

A 71-year-old patient primarily presented with a 2-year history of recurrent short episodes of spinning vertigo. Each of the episodes began with an altered feeling on the left side of the face, followed by a bitter taste on the left half of the tongue, and subsequently vertigo lasting for up to 15 s. The frequency of the attacks was high: up to 80 times per day. Laboratory tests revealed signs of a peripheral vestibular deficit on the left side. There were no signs of sensory or motor deficits or of altered taste between the episodes. An MRI of the brain showed an elongated basilar artery leading to an indentation of the facial and vestibulocochlear nerves on the left side.

Conclusion

We propose a neurovascular compression in the proximal part of two cranial nerves because of pulsatile compression by the elongated basilar artery with ephatic discharges as the cause of the recurrent episodes. Consistent with the theory of ephatic discharges, treatment with the sodium channel blocker lacosamide for over six months with a final dosage of 200 mg per day p.o. led to a significant reduction of the attack frequency and intensity. This treatment option with a sodium channel blocker should therefore not only be considered in vestibular paroxysmia but also in cases of paroxysmal dysgeusia.

Long-term Prognosis of Vertigo Attacks and Health-related Quality of Life Limitations in Patients With Vestibular Paroxysmia

OBJECTIVE

To explore the long-term course of outcomes in vestibular paroxysmia (VP).

STUDY DESIGN

Cross-sectional observational study with a retrospective collection of baseline data.

SETTING

Tertiary referral center.

PATIENTS

Adult patients who visited the Apeldoorn Dizziness Center between 2010 and 2020 and were diagnosed with definite or probable VP according to the Bárány Society criteria were contacted by telephone to complete a study-specific questionnaire. Baseline data were retrospectively collected from patients electronic medical records to allow comparison between baseline and follow-up data.

MAIN OUTCOME MEASURES

Vertigo attack frequency, use of carbamazepine and health-related quality of life (HRQoL) limitations were the primary outcomes. Secondary outcomes were the number of attack-free years and perceived effect of medication for VP.

RESULTS

Seventy three patients were included, 61 (84%) of whom agreed to participate in the follow-up study. Mean age was 55.0 (SD 13.1) years, 49.2% were females. Mean follow-up was 3.4 years (range 0.4-11.3). At follow-up, 44 responders (72%) still experienced vertigo attacks. Average attack frequency in the past 6 months was 307 (SD 451) at baseline and 153 (SD 279) at follow-up (p = 0.050). At follow-up, 19.7% (n = 12) of the responders reported to use or have used carbamazepine, 58% of patients who (had) used this medication reported a positive perceived effect. Overall, 71% (n = 31) of the responders reported to have limitations in one or more HRQoL items due to their VP.

CONCLUSION

Our study shows a rather unfavorable prognosis in patients with VP in terms of vertigo attacks and HRQoL limitations. After the initial diagnosis follow-up is warranted to monitor clinical outcomes in these patients.

Pharmacotherapy of cerebellar and vestibular disorders

PURPOSE OF REVIEW

Major therapeutic advances have been made in patients with episodic and progressive cerebellar ataxias, downbeat nystagmus and some vestibular disorders. We provide an update review on this subject highlighting important research findings from the last two years.

RECENT FINDINGS

Recently, the use of omaveloxolone for 2 years significantly improved upright stability in Friedreich's ataxia patients. In an open-label study, N-acetyl-l-leucine administered for 6-weeks significantly improved clinical impression of change, ataxia, and quality of life in patients with Niemann-Pick disease type C1. A 12-week treatment with dalfampridine was associated with improved standing balance in a subgroup of patients with multiple sclerosis. A gluten-free diet alone improved ataxia in half of patients with antiglutamic acid decarboxylase (GAD) ataxia, suggesting that gluten sensitivity might be part of the underlying pathogenesis in anti-GAD ataxia. In a head-to-head trial, both prolonged-release 4-aminopyridine (4-AP) and acetazolamide effectively reduced the attacks up to 60% in patients with episodic ataxia type 2 (EA2), albeit 4-AP had fewer adverse effects. Small observational studies have shown that patients with episodic vestibular syndrome who cannot be diagnosed as definite or probable vestibular migraine, might still improve vestibular symptoms following preventive treatment for migraine. The use of vitamin D supplementation in benign paroxysmal positional vertigo, steroids in acute unilateral vestibulopathy, and betahistine in Ménière's disease patients remains controversial.

SUMMARY

Although the use of several therapies is being established in the treatment of cerebellar and vestibular disorders, there is an urgent need for prospective controlled therapeutic trials.

Episodic Spontaneous Dizziness

PURPOSE OF REVIEW

Conditions causing recurrent spontaneous episodes of dizziness or vertigo span several medical specialties, making it challenging for clinicians to gain confidence in evaluating and managing the spectrum of episodic vestibular disorders. Patients are often asymptomatic and have normal examinations at the time of evaluation. Thus, diagnosis depends heavily on eliciting key features from the history. Overreliance on symptom quality descriptions commonly leads to misdiagnosis. The goal of this article is to provide the reader with a straightforward approach to the diagnosis and management of conditions that cause episodic spontaneous dizziness.

RECENT FINDINGS

Consensus diagnostic criteria have been established for vestibular migraine, Ménière disease, vestibular paroxysmia, and hemodynamic orthostatic dizziness/vertigo. Vertigo has been recognized as a common symptom in vertebrobasilar ischemia, cardiogenic dizziness, and orthostatic hypotension. Treatment recommendations for vestibular migraine still lack high-quality evidence, but controlled trials are occurring.

SUMMARY

The evaluation should start with a detailed description of the episodes from the patient and any observers. Rather than focusing first on whether the symptom quality is most consistent with vertigo, dizziness, lightheadedness, or unsteadiness, the clinician should clarify the timing (episode frequency and duration), possible triggers or circumstances (eg, position changes, upright posture), and accompanying symptoms. History should identify any auditory symptoms, migraine features, posterior circulation ischemic symptoms, vascular risk factors, clues for anxiety, and potentially relevant medications. Carefully selected testing can help secure the diagnosis, but excessive and indiscriminate testing can lead to more confusion. Treatments for these conditions are vastly different, so an accurate diagnosis is critical.

Rare Disorders of the Vestibular Labyrinth: of Zebras, Chameleons and Wolves in Sheep's Clothing

The differential diagnosis of vertigo syndromes is a challenging issue, as many - and in particular - rare disorders of the vestibular labyrinth can hide behind the very common symptoms of "vertigo" and "dizziness". The following article presents an overview of those rare disorders of the balance organ that are of special interest for the otorhinolaryngologist dealing with vertigo disorders. For a better orientation, these disorders are categorized as acute (AVS), episodic (EVS) and chronic vestibular syndromes (CVS) according to their clinical presentation. The main focus lies on EVS sorted by their duration and the presence/absence of triggering factors (seconds, no triggers: vestibular paroxysmia, Tumarkin attacks; seconds, sound and pressure induced: "third window" syndromes; seconds to minutes, positional: rare variants and differential diagnoses of benign paroxysmal positional vertigo; hours to days, spontaneous: intralabyrinthine schwannomas, endolymphatic sac tumors, autoimmune disorders of the inner ear). Furthermore, rare causes of AVS (inferior vestibular neuritis, otolith organ specific dysfunction, vascular labyrinthine disorders, acute bilateral vestibulopathy) and CVS (chronic bilateral vestibulopathy) are covered. In each case, special emphasis is laid on the decisive diagnostic test for the identification of the rare disease and "red flags" for potentially dangerous disorders (e. g. labyrinthine infarction/hemorrhage). Thus, this chapter may serve as a clinical companion for the otorhinolaryngologist aiding in the efficient diagnosis and treatment of rare disorders of the vestibular labyrinth.

Vestibular Migraine of Childhood and Recurrent Vertigo of Childhood: Diagnostic criteria Consensus document of the Committee for the Classification of Vestibular Disorders of the Bárány Society and the International Headache Society

This paper describes the diagnostic criteria for “Vestibular Migraine of Childhood”, “probable Vestibular Migraine of Childhood” and “Recurrent Vertigo of Childhood” as put forth by the Committee for the Classification of Vestibular Disorders of the Bárány Society (ICVD) and the Migraine Classification subgroup of the International Headache Society. Migraine plays an important role in some subgroups of children with recurrent vertigo. In this classification paper a spectrum of three disorders is described in which the migraine component varies from definite to possibly absent. These three disorders are: Vestibular Migraine of Childhood, probable Vestibular Migraine of Childhood and Recurrent Vertigo of Childhood. The criteria for Vestibular Migraine of Childhood (VMC) include (A) at least five episodes with vestibular symptoms of moderate or severe intensity, lasting between five minutes and 72 hours, (B) a current or past history of migraine with or without aura, and (C) at least half of episodes are associated with at least one migraine feature. Probable Vestibular Migraine of Childhood (probable VMC) is considered when at least three episodes with vestibular symptoms of moderate or severe intensity, lasting between five minutes and 72 hours, are accompanied by at least criterion B or C from the VMC criteria. Recurrent Vertigo of Childhood (RVC) is diagnosed in case of at least three episodes with vestibular symptoms of moderate or severe intensity, lasting between 1 minute and 72 hours, and none of the criteria B and C for VMC are applicable. For all disorders, the age of the individual needs to be below 18 years old. It is recommended that future research should particularly focus on RVC, in order to investigate and identify possible subtypes and its links or its absence thereof with migraine.

A Practical Approach to Vertigo: A Synthesis of the Emerging Evidence

Vestibular presentations represent a large financial and symptomatic burden of disease^1,2 , while remaining one of the most elusive presentations to accurately and confidently diagnose. A primary cause for this is that the same symptom can be the end-product of numerous aetiologies, and uncertainties can lead to unnecessary investigations and associated increased cost and delays in diagnosis. An effective method to narrow the diagnosis is firstly to determine, from a limited list, which type of vestibular syndrome the patient possesses, and then apply a focussed history and examination to define the most likely aetiology within that syndrome. This review provides a diagnostic approach to the vertiginous patient, outlining the underlying pathophysiology that accounts for the clinical symptoms and signs. With this approach, physicians should be able to diagnose the majority of common vestibular presentations and know when to refer the urgent, complex, or rare cases to sub-specialist neuro-otologists for prompt and appropriate management. This article is protected by copyright. All rights reserved.

Vestibular Disorders

BACKGROUND

Recent research findings have improved the understanding of the diagnosis, pathophysiology, genetics, etiology, and treatment of peripheral, central, and functional vestibular vertigo syndromes.

METHOD

A literature search, with special attention to the current classification, treatment trials, Cochrane analyses, and other meta-analyses.

RESULTS

There are internationally accepted diagnostic criteria for benign positional paroxysmal vertigo, Menière's disease, bilateral vestibulopathy, vestibular paroxysmia, and functional dizziness. Whether an acute vestibular syndrome is central or peripheral can usually be determined rapidly on the basis of the history and the clinical examination. "Cere - bellar vertigo" is a clinically important entity. For bilateral vestibulopathy, balance training is an effective treatment. For Menière's disease, preventive treatment with betahistine (48 mg and 144 mg per day) is not superior to placebo. For vestibular paroxysmia, oxcarbazepine has been shown to be effective. Treatments that are probably effective for functional dizziness include vestibular rehabilitation, cognitive behavioral therapy, and serotonin reuptake inhibitors.

CONCLUSION

The diagnostic assessment of vestibular syndromes is much easier for clinicians now that it has been internationally standardized. There is still a lack of randomized, controlled trials on the treatment of, for example, Menière's disease, vestibular migraine, and "cerebellar vertigo."

Advances in pharmacotherapy of vestibular and ocular motor disorders

INTRODUCTION

Vertigo and dizziness are common chief complaints of vestibular and ocular motor disorders (lifetime prevalence 30%). Treatment relies on physical, pharmacological, psychological and rarely surgical approaches. Eight groups of drugs are currently used in vestibular and ocular motor disorders, namely anti-vertiginous, anti-inflammatory, anti-menière's, anti-migrainous medications, anti-depressants, anti-convulsants, aminopyridines and agents that enhance vestibular plasticity.

AREAS COVERED

The purpose of this review is to summarize the pharmacological characteristics and clinical applications of medications that are used for peripheral, central and functional vestibular and ocular motor disorders. The level of evidence for the respective drugs is described alongside the pathophysiological premises supporting their use. The authors place particular focus on translation and back-translation in vestibular pharmacological research and the repurposing of known drugs for new indications and rare disorders.

EXPERT OPINION

The use of drugs in vestibular and ocular motor disorders is often based on open-label, non-controlled studies and expert opinion. In the future, strong evidence derived from RCTs is needed to support the effectiveness and tolerability of these therapies in well-defined vestibular and ocular motor disorders. Vestibular pharmacological research must be guided by a better understanding of the molecular targets relevant in the pathophysiology of vestibular and ocular motor disorders.