Horizontal Direction-Changing Positional Nystagmus and Vertigo: A Case of Vestibular Migraine Masquerading as Horizontal Canal BPPV

Prevalence of Horizontal Canal Variant in 3,975 Patients With Benign Paroxysmal Positional Vertigo: A Cross-sectional Study

Background and Objectives

Current understanding based on older studies is that pc-BPPV is far more common than hc-BPPV. Such studies are limited by small sample sizes, and often the supine roll test for hc-BPPV is not performed. To better estimate the prevalence of hc-BPPV, we studied a large cross-section of patients with VOG-diagnosed BPPV.

Methods

Using a cross-sectional study of patients with BPPV, we investigated patients referred to NeuroEquilibrium specialty clinics throughout India between January 1, 2021, and December 31, 2021. All patients were evaluated with video oculography (VOG) during positional tests, and all diagnoses were confirmed by a neurotologist and neurologist.

Results

Of 3,975 patients with VOG-confirmed and specialist-diagnosed BPPV (median age, 51 years; 56.6% women), pc-BPPV accounted for 1,901 (47.8%), hc-BPPV was seen in 1,842 (46.3%), and anterior canal BPPV was found in 28 (0.7%) patients.

Discussion

This study found that hc-BPPV is far more common than previously reported. It is important to perform the supine roll test in addition to the Dix-Hallpike in all patients suspected with BPPV. Better training to diagnose patients with BPPV and to accurately recognize the nystagmus pattern of hc-BPPV should be a priority.

Vestibular migraine treatment: a comprehensive practical review

Vestibular migraine is an underdiagnosed but increasingly recognised neurological condition that causes episodic vertigo associated with other features of migraine. It is now thought to be the most common cause of spontaneous (non-positional) episodic vertigo, affecting up to 1% of the population. A meta-analysis of preventative treatments for vestibular migraine was published in 2021 but the authors were unable to establish a preferred treatment strategy due to low quality of evidence and heterogeneity of study design and outcome reporting. There remains therefore a clinical need for pragmatic management guidelines specific to vestibular migraine using the available evidence. Here we provide a practical review utilising a systematic qualitative assessment of the evidence for abortive and preventative interventions in adults. The overall evidence base for vestibular migraine treatment is of low quality. Nevertheless, we provide practical treatment recommendations based on the available evidence and our experience to help guide clinicians treating patients with vestibular migraine. We also discuss how future clinical trials could be designed to improve the quality of evidence in this condition.

Update on diagnosis and differential diagnosis of vestibular migraine

BACKGROUND

Vestibular migraine (VM) is considered the most common cause of spontaneous episodic vertigo and the second most common cause of vertigo. However, without a biomarker or a complete understanding of the pathophysiology, VM remains underrecognized and underdiagnosed. Therefore, definite diagnostic criteria are urgently needed. Meanwhile, VM should be clearly differentiated from other similar diseases. This paper may help clinicians improve the diagnostic rate of VM and reduce the rate of misdiagnosis. A PubMed search was performed using the following terms: vestibular migraine, migraine-associated vertigo/dizziness, migraine-related vertigo, migraine-related vestibulopathy, benign recurrent vertigo, vertiginous migraine, migraine, headache, vertigo, dizziness, and diagnosis. This paper also summarizes the diagnostic criteria and differential diagnoses of VM. The diagnosis of VM is based on the symptoms, degree, frequency, and duration of the vestibular episodes, a history of migraine, and the temporal association of migraine symptoms with vestibular episodes in at least 50% of cases, while ruling out what may be due to other reasons. In addition to vestibular symptoms and migraine, transient auditory symptoms, nausea, vomiting, and susceptibility to motion sickness may also be associated with VM. Thus, VM should be differentiated from other diseases such as Meniere's disease, benign paroxysmal positional vertigo, migraine with brainstem aura, vestibular neuritis, posterior circulation ischemia, multiple lacunar infarction, vestibular paroxysmia, motion sickness, and episodic ataxia type 2.

CONCLUSION

Only if the diagnostic criteria of VM and differential diagnosis can be mastered clearly, we can make a definite diagnosis and treat patients properly.

Update on Nystagmus and Other Ocular Oscillations

This review reports on recent advances in understanding nystagmus and other involuntary eye movements. Advances in quantitative evaluations of eye movements using oculography, computational model simulations, genetics, and imaging technologies have markedly improved our understanding of the pathophysiology of involuntary eye movements, as well as their diagnosis and management. Patient-initiated capture of eye movements, especially when paroxysmal, and the online transfer of these data to clinicians would further enhance the ability to diagnose involuntary eye movements.

Update on benign paroxysmal positional vertigo

Benign paroxysmal positional vertigo (BPPV) is the most common cause of vertigo worldwide. This review considers recent advances in the diagnosis and management of BPPV including the use of web-based technology and artificial intelligence as well as the evidence supporting the use of vitamin D supplements for patients with BPPV and subnormal serum vitamin D.

Vestibular migraine and benign paroxysmal positional vertigo, close presentation dilemma

Background: Not only an association between benign paroxysmal positional vertigo (BPPV) and migraine have been recognized in the literature, but also, there are close similarities between BPPV and vestibular migraine (VM) presentations as both can be presented by very similar positional nystagmus.Aims/objectives: To prescribe relatively uncommon cases of positional nystagmus caused by VM that mimics positioning nystagmus of BPPV.Material and method: 12 patients were reviewed retrospectively in this study. All were subjected to full history taking, videonystagmography testing (VNG) and brain magnetic resonance imaging (MRI) with contrast. Provisionally, they were diagnosed with BPPV. After three attempts of repositioning sessions none of them improved. After exclusion of central insults using brain MRI, trial of anti-migraine medical treatment (50-100 Topiramate tablets once per day) for at least one month was prescribed to them.Results: 10 patients were completely cured on medical treatment and finally were diagnosed VM. Only 2 patients did not improve on medical treatment (for one month), were managed again by repeated repositioning maneuvers till finally improved and were diagnosed as resistant BPPV.Conclusions/significance: VM positional nystagmus can mimic BPPV nystagmus in some patients.

Pseudo-Benign Paroxysmal Positional Vertigo: A Retrospective Study and Case Report

Pseudo-benign paroxysmal positional vertigo (pseudo-BPPV) is a specific type of vestibular migraine disguised as benign paroxysmal positional vertigo, which is characterized by recurrent different types of positional and atypical positional vertigo with migraine features. It is easy to be misdiagnosed with BPPV at the first visit, which means that the ideal therapeutic effects are not achieved. Twenty-five cases of pseudo-BPPV with frequent changing positional vertigo were retrospected and the following key features help to identify the disease: recurrent positional and atypical positional vertigo, migrainous accompanying symptoms or migraine history, mild or indistinctive headaches, with or without impaired vestibular function, ineffective for simply reposition. And we found that vertigo in pseudo-BPPV can be preferable controlled by valproic acid combined with canalith repositioning procedure.

Benign Positional Paroxysmal Vertigo Treatment: a Practical Update

PURPOSE OF THE REVIEW

To define the best up-to-date practical approach to treat benign paroxysmal positional vertigo (BPPV).

RECENT FINDINGS

Both posterior and horizontal canal BPPV canalith repositioning maneuvers (Semont, Epley, and Gufoni's maneuvers) are level 1 evidence treatment for evidence-based medicine. The choice of maneuver (since their efficacy is comparable) is up to the clinician's preferences, failure of the previous maneuver, or movement restrictions of the patient. Maneuvers for controversial variants, such as anterior canal and apogeotropic posterior canal BPPV, have weaker evidence of efficacy. Despite this, these variants are increasingly diagnosed and treated. Maneuvers also play a role in the differential diagnosis with central vestibular disorders. Chair-assisted treatment may be of help if available while surgical canal plugging should be indicated in selected same-canal, same-side intractable severe BPPV. The primary evidence-based treatment strategy for BPPV should be physical therapy through maneuvers. Despite the high success rate of liberatory maneuvers, there is a low percentage of subjects who have unsatisfactory outcomes. These patients need to be investigated to identify recurrences, multiple canal involvement, associated comorbidities (migraine, persistent postural perceptual dizziness), or risk factors for recurrences (low vitamin D serum level). Future research should also identify the optimum maneuvers for variants whose diagnosis and treatment are still a matter of some debate.