Referral of the month - recurrent vertigo
Dr Louisa Murdin, consultant audiovestibular physician, advises on this case of long-standing vertigo
Dear Dr Murdin,
Thank you for seeing this 63-year-old man regarding his recurrent vertigo.
He is relatively new to our practice and arrived on a long-term prescription for betahistine.
There seems little doubt that his symptom is vertigo, as he clearly describes a rotatory illusion of movement. Each episode can last from an hour to the whole day, though there seems to be some secondary anxiety clouding the issue. Occasionally, he experiences a headache at the same time, but this is not consistent.
He’s had these symptoms for some years, but they are getting worse, with attacks every few months, for which he takes occasional prochlorperazine. I presume that he was thought to have possible Menière’s disease in view of the prescription for betahistine, but there is no associated deafness or tinnitus. The history does not suggest benign positional vertigo, either, as the episodes are not related to movement and last quite a long time.
Examination is normal and he has no relevant past medical history other than arthritis, for which he takes an NSAID with a PPI.
I’d be grateful for your advice regarding
- The likely diagnosis – I wondered if migrainous vertigo was a possibility? It certainly seems difficult to fit this into any specific vertigo category.
- What further investigation he should have.
- Whether it is logical to continue with betahistine given the lack of other features of Menière’s – does this drug help other forms of vertigo?
Many thanks for your letter about your patient with recurrent episodes of vertigo. You mention migrainous vertigo as a consideration and migraine is certainly the commonest cause of non-positional recurrent episodes of vertigo. The current favoured term for this condition is vestibular migraine. In vestibular migraine, patients experience recurrent episodes of vertigo, lasting from a few minutes to several hours in duration. This fits very well with your patient’s history. To make the diagnosis confidently, we need two other features to be present:
- A history of ‘normal’ (non-vestibular) migraine
- Migraine features present during his episodes
For the first of these criteria, you don’t mention a history of migraine in your patient, but in my experience it’s worth pressing patients about a possible migraine history. The characteristics of migraine headaches are that they last several hours, are unilateral, have a pulsing quality, are moderate or severe, are worse with routine physical activity and are associated with nausea, photophobia and phonophobia. Migraine is very common and often normalised and self-managed, so patients quite frequently have migraines without ever having presented to medical care. A history of migraine might have been long ago, in teens or early adulthood, so it has largely been forgotten.
As far as the second criterion is concerned, your patient has already described headaches with some of his vertigo episodes. Most patients with vestibular migraine have episodes of vertigo without headache and it’s not necessary for every attack to be linked with a headache to make the diagnosis. Other migrainous symptoms that can be associated with attacks are photophobia, phonophobia and visual aura. If the vertigo is very severe and incapacitating, the other features are less obviously noticeable to the patient, so it’s useful to ask specifically about these.
At this age, I would also consider the possibility of a vascular cause such as transient ischaemic attacks for his episodes. This is an important consideration in anyone in whom the episodes are associated with neurological symptoms like ataxia, dysarthria, true diplopia or visual-field defects, and also in anyone with vascular risk factors.
As with other forms of migraine, there’s no diagnostic test to do and the diagnosis is based very much on the history. If the diagnosis is clear from the history, the episodes have been going on a long time and there is a normal neurological examination with complete symptomatic recovery between episodes, then further investigation is usually unnecessary. Investigations are mostly useful in cases where there’s any doubt about the diagnosis. In this case, if the history of migraine and associated features is weak, it would be worth considering referral for further vestibular assessment (including pure tone audiometry) and consideration of imaging. This assessment would look for any evidence of the less common causes of isolated recurrent vertigo such as eighth nerve schwannoma, syphilis, Menière’s disease and perilymph fistula. I agree with your view that Menière’s disease is unlikely given that he has had several attacks already without any lateralised auditory symptoms such as deafness, tinnitus or aural fullness.
You ask about his betahistine - in the UK, betahistine is often held to be a specific treatment for recurrent vertigo related to Menière’s disease. In the USA betahistine is very rarely used for any indication. In Europe (outside the UK) it is widely used for recurrent vertigo of many different causes and not specifically for Menière’s disease. The evidence base that it works for Menière’s disease is weak. There is also low quality evidence that betahistine can be useful for all forms of recurrent vertigo. In its favour, it is very well tolerated with a low risk of adverse effects. In my view, it might be reasonable to use it in the short term while a diagnosis is worked out, however, the most logical approach with the highest chance of success for the patient is to work out a clear diagnosis for the recurrent vertigo and then treat the underlying cause.
There is a group of patients with recurrent episodes of vertigo in whom, even after thorough assessment, there are no clear pointers to migraine or Menière’s disease or any other pathology. These are often termed ‘benign recurrent vertigo’, postulated to have a migrainous origin and often treated as a form of vestibular migraine.
For vestibular migraine, acute infrequent episodes can be relieved with vestibular suppressants or antiemetics for nausea and vertigo, and the prochlorperazine that your patient is taking is a reasonable choice. It’s important to make sure that he understands that this should only be for short-term relief (less than a week) and is not for longer-term prevention of attacks. The buccal form of prochlorperazine can be useful where the attack has a rapid onset, since gastric stasis or frank emesis reduce absorption. Migraine headache can be managed along standard lines, with simple analgesia as a first-line management for infrequent episodes, taking care to avoid analgesic associated headache. Where the vertigo attacks are fairly frequent and interfering with quality of life, it’s worth considering migraine prophylaxis. At the moment there is no particular evidence that one antimigraine preventive agent is more effective for vestibular migraine than any other when it comes to prophylaxis, so the choice can be made as you would for other forms of migraine, according to comorbidities and potential for side effects. Beta blockers are a popular choice as a first-line agent, as recommended in current NICE guidance on migraine.
Secondary anxiety (as seen in your patient) is a common associate of vestibular migraine. Many patients will respond to well to a clear diagnosis and explanation of the symptoms. In some individuals, secondary anxiety exacerbates the symptoms and specific anxiety management strategies can be helpful. This is especially important where there are avoidance behaviours in between episodes.
Dr Louisa Murdin
- Migraine is the commonest cause of recurrent non-positional vertigo episodes.
- It is important to ensure patients with recurrent vertigo have a clear diagnosis as this will lead to appropriate condition-specific management.
- The evidence base for long-term use of betahistine in recurrent non-positional vertigo is weak, and this management strategy should therefore be viewed with circumspection.
Dr Louisa Murdin is a consultant in audiovestibular medicine at Guy’s and St Thomas’ NHS Foundation Trust and an honorary senior lecturer at the UCL Ear Institute.