szmtag In Reply (23.10.2020)
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The topic of cervical dizziness/vertigo has been the subject of controversial discussion for decades. But to date there are no convincing studies or clinical tests that support such a diagnosis, and no correlation exists between the extent of degenerative changes to the cervical spine and the symptoms. In most patients who are categorized under that diagnosis, another underlying cause can be found. Patients with vertigo/dizziness as their lead symptom may also complain of neck pain and tension. These are, however, not the cause but the consequence of the other disorders, because head movements often make the vertigo symptoms worse and patients therefore intuitively tense their neck muscles in order to keep their head still.

The vertebral artery has a role in dissections of the vertebral artery with brain stem/cerebellar ischemia and in the very rare entity of vertebral artery compression/occlusion syndrome: in horizontal head rotations, transient ischemic symptoms occur in the brain stem and cerebellum. The cause may be a unilateral vertebral artery stenosis in the PICA ending vertebral artery with compression of the contralateral vertebral artery when the head is rotated and consequently reduced blood flow in the vertebrobasilar system.

Regarding the term vertigo and dizziness in the elderly we wish to comment that age per se is not a disorder. Bilateral vestibulopathies and presbyvestibulopathy (1) are not rare but common causes of dizziness, unsteadiness and instability of stance and/or gait especially in older people, but they are diagnosed too rarely. Oscillopsia is among the symptoms of acute unilateral vestibulopathy in the acute phase, caused by peripheral vestibular spontaneous nystagmus. We agree that in benign peripheral positional paroxysmal vertigo, one isolated release maneuver is insufficient.

The diagnostic criteria of the Bárány Society fall into two categories: Menière’s disease and probable Menière’s disease. The latter also includes the types of hearing impairment that are untypical for Menière’s disease. In our experience, betahistine is tolerated well even in high and very high dosages as an individual case of off-label use. But according to the BEMED study, a dose of 144 mg/d is not superior to placebo with a high placebo-effect in this study. Long term treatment (>6–12 months) using higher dosages (for example, 3 × 96 mg/d or higher) does, in our experience, have a prophylactic effect in most patients, but this will have to be investigated in placebo controlled studies. No placebo-controlled studies have thus far been carried out of vestibular migraine and triptan treatment for attacks.

Reaching a diagnosis in a patient with vertigo as their lead symptom is simple but not trivial. In most cases it does not require extensive laboratory examinations except for the video head impulse test and the caloric test. Imaging is primarily indicated in acute vestibular syndrome, if a central lesion is suspected (stroke), and if there is a clinical suspicion of a space occupying lesion in the cerebellopontine angle. Laboratory examinations and imaging are carried out far too often in patients whose lead symptom is vertigo/dizziness.

There is a whole range of causes of vertigo—for example, the mentioned “non-benign” peripheral vestibular syndromes -, which are diagnosed by examination from a ENT specialist, and, where indicated, imaging modalities, and which have therapeutic consequences.

DOI: 10.3238/arztebl.2020.0735c

On behalf of the authors

Prof. Dr. med. Dr. h.c. Michael Strupp, FRCP, FANA, FEAN

Neurologische Klinik und Deutsches Zentrum für Schwindel
und Gleichgewichtsstörungen

Ludwig-Maximilians-Universität, München, Campus Großhadern

Michael.Strupp@med.uni-muenchen.de

Conflict of interest statement

Prof. Strupp owns stock in Intra Bio, as well as related patents. He serves as a paid consultant for Abbott, Actelion, AurisMedical, Heel, IntraBio, and Sensorion. He has received lecture honoraria from Abbott, Actelion, Auris Medical, Biogen, Eisai, Grünenthal, GSK, Hennig Pharma, Interacoustics, MSD, Mylan, Otometrics, Pierre-Fabre, TEVA, and UCB. He is the distributor of the M glasses. He has received financial support from Abbott, Decibel Interacoustics, and Natus for a research project that he initiated, as well as third-party research support from Auris Medical, Biogen, Decibel, and Heel.

1.
Agrawal Y, van de Berg R, Wuyts F, et al.: Presbyvestibulopathy: Diagnostic criteria consensus document of the classification committee of the Bárány Society. J Vestib Res 2019; 29: 161–70 CrossRef MEDLINE
2.
Lopez-Escamez JA, Carey J, Chung WH, et al.: Diagnostic criteria for Meniere‘s disease. J Vestib Res 2015; 25: 1–7 CrossRef MEDLINE
3.
Strupp M, Dlugaiczyk J, Ertl-Wagner BB, Rujescu D, Westhofen M, Dieterich M: Vestibular disorders—diagnosis, new classification and treatment. Dtsch Arztebl Int 2020; 117: 300–10 VOLLTEXT
1.Agrawal Y, van de Berg R, Wuyts F, et al.: Presbyvestibulopathy: Diagnostic criteria consensus document of the classification committee of the Bárány Society. J Vestib Res 2019; 29: 161–70 CrossRef MEDLINE
2.Lopez-Escamez JA, Carey J, Chung WH, et al.: Diagnostic criteria for Meniere‘s disease. J Vestib Res 2015; 25: 1–7 CrossRef MEDLINE
3.Strupp M, Dlugaiczyk J, Ertl-Wagner BB, Rujescu D, Westhofen M, Dieterich M: Vestibular disorders—diagnosis, new classification and treatment. Dtsch Arztebl Int 2020; 117: 300–10 VOLLTEXT

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