Abstract
The diagnosis and management of vertigo remains a challenge for clinicians, including general neurology. In recent years there have been advances in the understanding of established vestibular syndromes, and the development of treatments for existing vestibular diagnoses. In this ‘update’ I will review how our understanding of previously “unexplained” dizziness in the elderly is changing, explore novel insights into the pathophysiology of vestibular migraine, and its relationship to the newly coined term ‘persistent postural perceptual dizziness’, and finally discuss how a simple bedside oculomotor assessment may help identify vestibular presentations of stroke.
Highlights
The world of dizziness has experienced a dramatic change over the last 3 decades, as new treatable syndromes have been identified, and novel treatments developed for existing vestibular diagnoses
The commonest differential diagnosis for benign paroxysmal positional vertigo (BPPV) is vestibular migraine, a condition that is increasingly recognised outside specialist centres, but remains under-diagnosed
vestibular migraine (VM) in turn is a common precursor to a more chronic form of dizziness recently renamed persistent postural perceptual dizziness (PPPD), and there has been a growth in the unravelling of the neurobiology of this disorder
Summary
The world of dizziness has experienced a dramatic change over the last 3 decades, as new treatable syndromes have been identified, and novel treatments developed for existing vestibular diagnoses. Box 1 Bárány Society diagnostic criteria for persistent postural perceptual dizziness (A) One or more symptoms of dizziness, unsteadiness or non-spinning vertigo on most days for at least 3 months Symptoms last for prolonged (hours-long) periods of time, but may wax and wane in severity Symptoms need not be present continuously throughout the entire day (B) Persistent symptoms occur without specific provocation, but are exacerbated by three factors: upright posture, active or passive motion without regard to direction or position, and exposure to moving visual stimuli or complex visual patterns (C) The disorder is triggered by events that cause vertigo, unsteadiness, dizziness, or problems with balance, including acute, episodic or chronic vestibular syndromes, other neurological or medical illnesses, and psychological distress When triggered by an acute or episodic precipitant, symptoms settle into the pattern of criterion A as the precipitant resolves, but may occur intermittently at first, and consolidate into a persistent course When triggered by a chronic precipitant, symptoms may develop slowly at first and worsen gradually (D) Symptoms cause significant distress or functional impairment (E) Symptoms are not better accounted for by another disease or disorder clinically [22] Whether such pro-inflammatory markers are capable of segregating typical migraine from VM remains to be seen. Application of artificial intelligence and tele-consultation [42], incorporating a structured oculomotor assessment, and perhaps including vascular/perfusion imaging for isolated vestibular syndromes, may be future perspectives for real-time decision making in acute dizziness and vertigo
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