Michael von Brevern

Burden of Dizziness and Vertigo in the Community

BACKGROUND Dizziness and vertigo are common, however, the cause often remains unexplained. The percentage of vertigo of vestibular origin in individuals with unselected dizziness has not been well examined, and its underestimation may lead to diagnostic bias in primary care. The purpose of this study was to reassess the burden of dizziness in the community and to quantify the contribution of vertigo of vestibular origin. METHODS A nationally representative sample of 4869 adults living in Germany was screened for moderate or severe dizziness, and 1003 individuals with dizziness underwent validated neurotologic interviews to differentiate vestibular vertigo from nonvestibular dizziness according to explicit diagnostic criteria. RESULTS Dizziness/vertigo had a prevalence of 22.9% in the last 12 months and an incidence (first episode of dizziness/vertigo) of 3.1%. For vestibular vertigo, the prevalence was 4.9% [corrected] and the incidence was 1.4%. We also found that 1.8% of unselected adults consulted a physician in the last 12 months for [corrected] dizziness/vertigo (0.9% for vestibular vertigo). Compared with nonvestibular dizziness, vestibular vertigo was more frequently followed by medical consultation (70% vs 54%; P < .001), sick leave (41% vs 15%; P < .001), interruption of daily activities (40% vs 12%; P < .001), and avoidance of leaving the house (19% vs 10%; P = .001). However, more than half of the participants with vestibular vertigo reported nonvestibular diagnoses. Age- and sex-adjusted health-related quality of life was lower in individuals with dizziness and vertigo compared with dizziness-free control subjects. CONCLUSIONS The occurrence of dizziness and vertigo is frequent and associated with a considerable personal and health care burden. Vestibular vertigo accounts for a considerable percentage of this burden, which suggests that diagnosis and treatment of frequent vestibular conditions are important issues in primary care.

Classification of vestibular symptoms: Towards an international classification of vestibular disorders

Alexandre Bisdorffa,∗, Michael Von Brevernb, Thomas Lempertc and David E. Newman-Tokerd Department of Neurology, Centre Hospitalier Emile Mayrisch, L-4005 Esch-sur-Alzette, Luxembourg Vestibular Research Group Berlin, Department of Neurology, Park-Klinik Weissensee, Berlin, Germany Vestibular Research Group Berlin, Department of Neurology, Schlosspark-Klinik, Berlin, Germany Department of Neurology, The Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA

Migrainous vertigo presenting as episodic positional vertigo

Migraine can cause vestibular symptoms including positional vertigo. Of 362 consecutive patients presenting with positional vertigo, 10 with migrainous vertigo mimicking benign paroxysmal positional vertigo (BPPV) were identified. The following factors help to distinguish migrainous positional vertigo from BPPV: short-duration symptomatic episodes and frequent recurrences, manifestation early in life, migrainous symptoms during episodes with positional vertigo, and atypical positional nystagmus.

Vestibular migraine Long-term follow-up of clinical symptoms and vestibulo-cochlear findings

Objective: The aim of the study was to assess the evolution of clinical symptoms and vestibulo-cochlear function in patients with definite vestibular migraine (dVM). Methods: We reassessed 61 patients (54 women, 7 men, aged 24–76 years) with dVM according to validated diagnostic criteria after a median follow-up time of 9 years (range, 5.5–11). Assessment comprised a clinical interview and neurotologic examination, including pure-tone audiometry and caloric testing. Results: The majority of patients (87%) had recurrent vertigo at follow-up. Frequency of vertigo was reduced in 56%, increased in 29%, and unchanged in 16%. Impact of vertigo was severe in 21%, moderate in 43%, and mild in 36%. Eighteen percent reported mild persistent unsteadiness. Interictal ocular motor abnormalities had increased from 16% initially to 41% of patients at follow-up. The most frequent finding was positional nystagmus (PN), in 28%, including definite central-type PN in 18%. However, only 1 of 9 patients with ocular motor abnormalities at initial presentation showed similar findings on follow-up. Concomitant cochlear symptoms with vertigo had increased from 15% initially to 49%. Eleven patients (18%) had developed mild bilateral sensorineural hearing loss, which also involved the low-frequency range. Conclusions: The majority of patients continue to have recurrent vertigo in the long-term evolution of VM, and the impact of vertigo may remain severe. Whereas interictal ocular motor abnormalities may show some variation over time, vestibulo-cochlear dysfunction progresses slowly in some patients with VM. Interictal central-type PN may help distinguish VM from peripheral vestibular disorders such as Ménière disease.

Vestibular migraine – validity of clinical diagnostic criteria:

Background: Clinical recognition of vestibular migraine (VM) is still hampered by the lack of consensus diagnostic criteria. The aim of this study is a long-term evaluation of clinical criteria for definite (dVM) and probable (pVM) vestibular migraine. Methods: We re-assessed 75 patients (67 women, age 24–76 years) with dVM (n = 47) or pVM (n = 28) according to previously published criteria after a mean follow-up of 8.75 ± 1.3 years. Assessment included a comprehensive neurotological clinical examination, pure tone audiometry and caloric testing. Results: dVM was confirmed in 40 of 47 patients with a prior diagnosis of dVM (85%). Fourteen of 28 patients initially classified as pVM met criteria for dVM (50%), nine for pVM (32%). Six additional patients with dVM and two with pVM had developed mild sensorineural hearing loss, formally fulfilling criteria for bilateral Menière’s disease (MD), but had clinical features atypical of MD. Seven of these also met criteria for dVM at follow-up. The initial diagnosis was completely revised for four patients. Conclusion: Although VM diagnosis lacks a gold standard for evaluation of diagnostic criteria, repeated comprehensive neurotological evaluation after a long follow-up period indicates not only high reliability but also high validity of presented clinical criteria (positive predictive value 85%). Half of patients with pVM evolve to meet criteria for dVM. However, in a subgroup of VM patients with hearing loss, criteria for dVM and MD are not sufficiently discriminative.

Benign paroxysmal positional vertigo: Diagnostic criteria

This article presents operational diagnostic criteria for benign paroxysmal positional vertigo (BPPV), formulated by the Committee for Classification of Vestibular Disorders of the Bárány Society. The classification reflects current knowledge of clinical aspects and pathomechanisms of BPPV and includes both established and emerging syndromes of BPPV. It is anticipated that growing understanding of the disease will lead to further development of this classification.

Migrainous vertigo: mutation analysis of the candidate genes CACNA1A, ATP1A2, SCN1A, and CACNB4.

Background.—Migrainous vertigo (MV) is increasingly recognized as a common cause of episodic vertigo. MV displays several clinical similarities with familial hemiplegic migraine (FHM) and episodic ataxia type 2 (EA‐2), which have been linked to mutations in 3 genes, CACNA1A, encoding a neuronal calcium channel α subunit, ATP1A2, encoding a catalytic subunit of a Na+/K+‐ATPase, and most recently the voltage‐gated sodium channel SCN1A. The present study explored the hypothesis that mutations in CACNA1A, ATP1A2, SCN1A, and the calcium channel β4 subunit CACNB4 confer susceptibility to MV.

Continuous vertigo and spontaneous nystagmus due to canalolithiasis of the horizontal canal

The authors present a patient with benign paroxysmal positional vertigo of the right horizontal semicircular canal who developed persistent vertigo with spontaneous horizontal nystagmus to the left and caloric hypoexcitability on the right after a head shaking maneuver. Both spontaneous nystagmus and canal paresis resolved after repeated shaking of the head. The most probable mechanism of this type of vertigo is plugging of the horizontal canal by otoconial particles with a negative endolymph pressure between plug and cupula.

Accompanying Symptoms Overlap during Attacks in Menière’s Disease and Vestibular Migraine

Menière’s disease and vestibular migraine (VM) are the most common causes of spontaneous recurrent vertigo. The current diagnostic criteria for the two disorders are mainly based on patients’ symptoms, and no biological marker is available. When applying these criteria, an overlap of the two disorders is occasionally observed in clinical practice. Therefore, the present prospective multicenter study aimed to identify accompanying symptoms that may help to differentiate between MD, VM, and probable vestibular migraine (pVM). Two hundred and sixty-eight patients were included in the study (MD: n = 119, VM: n = 84, pVM: n = 65). Patients with MD suffered mainly from accompanying auditory symptoms (tinnitus, fullness of ear, and hearing loss), while accompanying migraine symptoms (migraine-type headache, photo-/phonophobia, visual aura), anxiety, and palpitations were more common during attacks of VM. However, it has to be noted that a subset of MD patients also experienced (migraine-type) headache during the attacks. On the other hand, some VM/pVM patients reported accompanying auditory symptoms. The female/male ratio was statistically higher in VM/pVM as compared to MD, while the age of onset was significantly lower in the former two. The frequency of migraine-type headache was significantly higher in VM as compared to both pVM and MD. Accompanying headache of any type was observed in declining order in VM, pVM, and MD. In conclusion, the present study confirms a considerable overlap of symptoms in MD, VM, and pVM. In particular, we could not identify any highly specific symptom for one of the three entities. It is rather the combination of symptoms that should guide diagnostic reasoning. The identification of common symptom patterns in VM and MD may help to refine future diagnostic criteria for the two disorders.

Epidemiological evidence for a link between vertigo and migraine

Both migraine and dizziness/vertigo rank among the most common complaints in the general population. Worldwide, the lifetime prevalence of migraine is about 14%. Approximately 20% to 30% of the general population are affected by dizziness and vertigo. Given the high prevalence of vertigo and migraine in the general population it is not surprising that many patients suffer from both symptoms. Nonetheless, in the last decade epidemiological arguments have progressively accumulated to strengthen the hypothesis that vertigo is linked to migraine beyond a mere chance concurrence. Several studies with selected patient groups have shown that the prevalence of vertigo is increased in patients with migraine. Vice versa, patients presenting to a dizziness clinic have a history of migraine more often than would be expected by chance. The epidemiological link between vertigo and migraine has recently been confirmed on the population level. The relation between vertigo and migraine is intricate. In vestibular migraine, vertigo is conceptualized as a vestibular symptom caused by migraine. Vestibular migraine is the most common cause for recurrent spontaneous vertigo with a lifetime-prevalence in the general population of about 1%. Other vestibular disorders that display an increased prevalence of migraine are benign paroxysmal positional vertigo and Menières disease. Furthermore, migraine is associated with motion sickness, rare ataxia disorders and psychiatric syndromes that can also manifest with vertigo and dizziness.