Persistent-postural perceptual dizziness (PPPD): Yes, it is a psychosomatic condition!

Vestibular migraine: an update

PURPOSE OF REVIEW

We performed a narrative review of the recent findings in epidemiology, clinical presentation, mechanisms and treatment of vestibular migraine.

RECENT FINDINGS

Vestibular migraine is an underdiagnosed condition that has a high prevalence among general, headache and neuro-otology clinics. Vestibular migraine has a bimodal presentation probably associated with a hormonal component in women. These patients could have a complex clinical phenotype including concomitant autonomic, inflammatory or connective tissue conditions that have a higher prevalence of psychological symptoms, which may mistakenly lead to a diagnosis of a functional neurological disorder. A high proportion of patients with postural perceptual persistent dizziness have a migraine phenotype. Independently of the clinical presentation and past medical history, patients with the vestibular migraine phenotype can respond to regular migraine preventive treatments, including those targeting the calcitonin gene-related peptide pathways.

SUMMARY

Vestibular migraine is an underdiagnosed migraine phenotype that shares the pathophysiological mechanisms of migraine, with growing interest in recent years. A thorough anamnesis is essential to increase sensitivity in patients with unknown cause of dizziness and migraine treatment should be considered (see supplemental video-abstract).

A review on the alterations in the brain of persistent postural-perceptual dizziness patients and non-pharmacological interventions for its management

Persistent postural perceptual dizziness (PPPD) is a relatively newer term, and this term is included in the International Classification of Diseases in its 11th revision. The typical features of PPPD include the presence of persistent dizziness, non-spinning vertigo, and unsteadiness, and these symptoms are exacerbated during upright posture, movement, or visual stimuli. Moreover, the structural changes have also been identified in the brains of PPPD patients, particularly in visual, vestibular, and limbic areas. These include a decrease in the volume and gyration of gray matter, a decrease in the blood flow to the cortex region, and alterations in the structural and functional connectivity, particularly in the visual-vestibular networks. Moreover, the impairment in sensory processing is restricted not only to the vestibular and visual regions; instead, there is a generalized impairment in the sensory processing, and thus, there is a multisensory dimension of sensory impairment. Selective serotonin uptake inhibitors and serotonin-norepinephrine reuptake inhibitors are the mainstay drugs for the management of PPPD patients. However, a significant proportion of PPPD patients do not show improvement in response to standard drug therapy. The employment of alternative and complementary treatment strategies, including vestibular rehabilitation therapy, cognitive behavioral therapy, and non-invasive vagal nerve stimulation, is effective in the management of PPPD patients. The present review discusses the alterations in the brains of PPPD patients along with the possible non-pharmacological treatment options in these types of patients.