Research in Vestibular Science

Review

Vestibular Migraine: A Recent Update on Diagnosis and Treatment: Young Seo Kim, Hak Seung Lee; Res Vestib Sci. 2022;21(3):67-74. Published online September 15, 2022; DOI: https://doi.org/10.21790/rvs.2022.21.3.67

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Abstract PDF: Vestibular migraine (VM) is a variant of migraine resulting in vestibular symptoms in addition to symptoms typical of migraine. However, without a biomarker or a complete understanding of the pathophysiology, VM remains underrecognized and underdiagnosed. Therefore, the diagnosis of VM is still challenging. Meanwhile, VM should be clearly differentiated from other similar diseases. Here, we highlight these challenges, discuss common vestibular symptoms and clinical presentations in VM, and review the current aspects of its clinical diagnosis and evaluation. The concepts related to the treatment of VM are also discussed.

Original Article

Canal Dysfunction Detected by Video Head Impulse Test in Patients with Vestibular Migraine and Its Relationship with Symptomatic Improvement: Ji Won Choi, Won Sub Lim, Sung Seok Ryu, Yeonjoo Choi, Sang Hun Lee, Seung Cheol Ha, Hong Ju Park; Res Vestib Sci. 2022;21(2):46-52. Published online June 15, 2022; DOI: https://doi.org/10.21790/rvs.2022.21.2.46

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Abstract PDF: Objectives
Video head impulse test (vHIT) can evaluate function of the vestibuloocular reflex for high frequency range of head rotation. We aimed to characterize the abnormal patterns of canal dysfunction by vHIT in vestibular migraine (VM) and evaluate the relationship between the presence of canal dysfunction and symptomatic improvement.
Methods
Eighty-seven patients with VM were included. Abnormality of vHIT at the initial examination was determined by the vHIT gain and the degrees of the corrective saccades at each canal and each side. The relationship between the abnormal patterns and the symptomatic improvement (no need for preventive medication) after modification of life styles and preventive medications for 1, 3, and 6 months was evaluated.
Results
Abnormal vHIT of the lateral canal was 13.8% when determined by the gain criteria and 31.0% when based on both gain and corrective saccade, regardless of the side. Abnormal vHIT of the superior and posterior canals were 18.4% and 27.6%, regardless of the side. Abnormal vHIT at any canal and side was observed in 47%. Patients showed symptomatic improvement in 29.9%, 71.3%, and 88.5% after modification of life styles and preventive medications for 1, 3, and 6 months. Abnormal vHIT results of canals were significantly related to the poor response to preventive mediations.
Conclusions
Prolonged preventive medication was required for symptomatic improvement in VM patients when vHIT results of any canals were abnormal, suggesting that peripheral vestibular abnormality is closely related to the pathophysiology of vestibular migraine.

Review

Benign Paroxysmal Positional Vertigo: Diagnostic Criteria and Updated Practice Guideline in Diagnosis: Dae Bo Shim; Res Vestib Sci. 2020;19(4):111-119. Published online December 15, 2020; DOI: https://doi.org/10.21790/rvs.2020.19.4.111

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Abstract PDF: Benign paroxysmal positional vertigo (BPPV) is the most common cause of recurrent vertigo that is characterized by sudden onset of vertigo elicited by positional change. American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS) and American Academy of Neurology provided clinical practice guideline for BPPV in 2008. Since then, Bárány Society has published BPPV diagnostic criteria in 2015, and AAO-HNS has revised BPPV clinical practice guideline in 2017 to publish update version. This article reviewed recent diagnostic criteria for BPPV included in the International Classification of Vestibular Disorders of Bárány Society and updated practice guideline in the BPPV diagnosis presented by AAO-HNS.

Symposium I

History Taking of Headache Patients: Byung Kun Kim; Res Vestib Sci. 2013;12:S11-S15. Published online June 1, 2013

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Abstract PDF: Headache is a most common complaint in neurological outpatient clinic. It has diverse underlying causes and numerous patterns of presentation. All headaches can be divided into primary and secondary headaches. More than ninety percent of headaches seen in clinical practice are due to primary headaches-most of them are tension type headache or migraine-where there are no confirmatory tests. A comprehensive history taking is critical for the correct diagnosis. Headache history taking is an art that needs constant practice. This review aims to discuss the way to go about taking a quick and correct history in headache patients.

Symposium III

Diagnosis and Treatment of Vertical Canal Benign Paroxysomal Positional Vertigo: Min Gu Lee, Sung Kwang Hong; Res Vestib Sci. 2013;12:S73-S76. Published online June 1, 2013

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Abstract PDF: Benign paroxysmal positional vertigo (BPPV) is inner ear disorder caused by a displacement by otoconia from the utricle into semicircular canal (SCC). It is usually present as a definite vertigo spell induced by change in head position. Even though the posterior canal is by far most frequent, BPPV can involve any SCC. The diagnosis is confirmed by typical clinical presentation and positional tests. The aim of the review article was to provide a current opinion regarding vertical canal BPPV.

Original Article

Multicenter Study on the Clinician’s Diagnostic and Therapeutic Approaches for Benign Paroxysmal Positional Vertigo in Korea: Eun Ju Jeon, Won Ho Chung, Jeong Hwan Choi, Eui Cheol Nam, Hong Ju Park, Jong Dae Lee, Won Sang Lee, Kyu Sung Kim, Eui Kyung Goh, Ja Won Koo, Min Bum Kim, Min Beom Kim, Se Hyung Kim, Young Jin Kim, Chang Hee Kim, Sung Il Nam, Seog Kyun Mun, Ga Young Park, Sang Yoo Park, Shi Nae Park, Chang Hoon Bae, Sung Hyun Boo, Myung Whan Suh, Jae Hyun Seo, Eun Jin Son, Jae Jun Song, Jae Jin Song, Joong Wook Shin, Dae Bo Shim, Seong Ki Ahn, Hye Youn Youm, Shin Young Yoo, Dong Hee Lee, Seung Hwan Lee, Chang Ho Lee, Hyun Seok Lee, Hwan Ho Lee, Hyo Jeong Lee, Yun Hoon Choung, Seung Hyo Choi, Jee Sun Choi, Seok Min Hong, Sung Kwang Hong; Res Vestib Sci. 2013;12(3):79-92.

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Abstract: Background and Objectives: It is necessary to establish the most efficient diagnostic and therapeutic method for benign paroxysmal positional vertigo (BPPV), which is appropriate for Korean healthcare system. We aimed to evaluate current state of Korean clinician’s diagnostic and therapeutic approaches for BPPV. Materials and Methods: A 16-item survey was emailed to the members of dizziness department of Otology Research Interest Group in the Korean Otologic Society (n=68). 43 were returned and analyzed. Results: All respondents (100%) used Dix-Hallpike test as a diagnostic tool for vertical canal-BPPV. Supine roll test was used for diagnosing lateral canal BPPV in nearly all the respondents (97.7%). Epley maneuver was chosen as otolith repositioning maneuver (ORM) for posterior canal BPPV in all respondents and barbecue rotation (BBQ) was used for treating lateral canal BPPV with geotropic nystagmus in 95.3% of respondents. Extreme variation was noted for therapeutic approach of lateral canal BPPV with ageotropic nystagmus BBQ, with 4 kinds of ORM and adjunctive measures to liberate otolith from cupula, while BBQ was again the most commonly used ORM (76.7%). Conclusion: The development of practical and efficient ORM for lateral canal BPPV with ageotropic nystagmus is necessary.

Reviews

Diagnosis of Benign Paroxysmal Positional Vertigo: Sun Young Oh; Res Vestib Sci. 2013;12(3):73-78.

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Abstract: Benign paroxysmal positional vertigo (BPPV) is a clinical syndrome characterized by brief recurrent episodes of vertigo triggered by changes in head position with respect to gravity. BPPV is the most common cause of recurrent vertigo, with a lifetime prevalence of 2.4%. In this review article, the diagnosis of BPPV involving the posterior, horizontal and anterior semicircular canal are described.

Diagnosis and Differential Diagnosis of Migrainous Vertigo: Seong Hae Jeong; Res Vestib Sci. 2012;11(2):45-50.

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Abstract PDF: Migrainous vertigo is one of common recurrent vestibular disorders. Because the diagnostic criteria have not been yet settled internationally, we have a difficulty in both diagnosis and research in migraineurs with vertigo. Literature about the diagnostic criteria of migrainous vertigo and its differential diagnosis were reviewed. Until now, the criteria proposed by Neuhauser et al. is regarded as most adequate in diagnosis of migrainous vertigo. Differential diagnosis of migrainous vertigo should be guided by distinction of vestibular symptoms and nonvestibular dizziness and consider the common causes of recurrent vertigo. Just like migraine itself, migrainous vertigo is diagnosed on the basis of history and exclusion of other vestibular disorders mimicking migrainous vertigo. Therefore, delicate history taking is the most important in diagnosis and management of patients with migrainous vertigo.

Original Articles

Clinical Review of Dizziness Patients Who Visited Emergency Room: Ki Yong Kim, Hyun Jung Min, Seung Hwan Lee, Chul Won Park; Res Vestib Sci. 2011;10(2):56-62.

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Abstract PDF: Background and Objectives: As most dizziness symptoms are vaigue, and misdiagnosis of central dizziness can be life threatening, diagnosis of the dizziness is difficult. Especially, in the emergency room with a restricted environment, it must be more difficult. The aim of this study is to find out and correct the aspects requiring a modification for diagnosis in patients of dizziness who visited emergency room. Materials and Methods: The authors retrospectively have reviewed the charts of 458 patients with dizziness who visited the emergency room at Hanyang University Guri Hospital from April 2008 to March 2009 and researched the various informations such as diagnosis, clinical feature, physical findings, present illness, past history, consulted department, and visiting season, etc. Results: The average age of patients was 61 years old. Even though there was a difference at the diagnosis distribution between age groups, non specific dizziness and benign paroxysmal positional vertigo was the most frequent diagnosis. Checking the dizziness characters like whirling sense, autonomic symptoms and progressing features was important. And vestibular function tests such as nystagmus test and rotatory test like post head shaking or head thrust test were helpful for differential diagnosis of dizziness in emergency room. Patients with central vertigo were older (71.2 year) and had more past medical histories. But there was no seasonal frequency difference of dizziness.Conclusion: As at emergency room, the differential diagnosis of dizziness is important but difficult, integrated medical knowledge of several departments associated with dizziness is required.

Diagnostic Value of Vestibular Evoked Myogenic Potential in Acoustic Neuroma: Young Jin Ahn, Sung Kwang Hong, Ji Soo Kim, Ja Won Koo; J Korean Bal Soc. 2007;6(2):138-142.

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Abstract PDF: Background and Objectives: Considering vestibular evoked myogenic potential (VEMP) represents functional integration of the inferior vestibular nerve and large proportion of acoustic neuroma (AN) originate from inferior vestibular nerve, VEMP test may provide more valuable information than ABR and the caloric test in terms of evaluating functional integration as well as screening test. Authors hope to clarify such hypothesis and also analyzed if parameters differ between cochlear lesion and retrocochlear lesion. Materials and Methods: Authors analyzed the results of VEMP test in 27 patients (10 males and 17 females) of AN and in 24 patients (9 males and 15 females) of unilateral definite Meniere’s disease (MD). Right-left difference of interpeak latency (IPL) and interaural amplitude difference (IAD) were used as parameters of VEMP. Longest diameter of the enhanced area was measured as the size of tumor on the axial view of Gadolium enhanced T1 weighted magnetic resonance image. Results: VEMP was abolished in 15 out of 27 AN patients (54.5%). Among the remaining 12 patients, 1 patient showed increased IPL and IAD at same time, while 2 patients exhibited increased IAD. The mean diameter of tumor in the group who showed positive VEMP waves was significantly smaller (0.95 cm) than that of abolished VEMP group (2.22 cm)(p=0.004). Similar tendency was also present in ABR and Caloric test. However, there was not significant difference between MD and AN in the latencies and amplitudes. Conclusions: VEMP test may not provide diagnostic information in smaller AN, especially less than 1 cm. And parameters of VEMP were not differ between cochlear and retrocochlear lesion. However, VEMP response seems still important for the comprehensive understanding of peripheral cochleovestibular status in addition to ABR and caloric test.

Case Report

Bilateral Inversion of Initial Nystagmus in Benign Paroxysmal Positional Vertigo of Horizontal Canal: Myung Whan Suh, Sang Wook Kim, Min Hyun Park, Ji Soo Kim, Ja Won Koo; J Korean Bal Soc. 2006;5(2):299-306.

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Abstract PDF: Horizontal canal benign paroxysmal positional vertigo (HC-BPPV) is characterized by direction-changing nystagmus of the horizontal component induced by lateral head turning in supine position. Yet, some patients with HC-BPPV show nystagmus inversion during head turning to one side. And, mostly, the nystagmus started in a geotropic direction and the inversion was observed only when the head is turned to the lesion side. Reversal of the clot movement in the canal and sensory adaptation were suggested as the hypothesis for such finding. However, bilateral inversion of geotropic nystagmus into apogeotropic nystagmus in HC-BPPV has seldom been described before. In this paper, the authors presented the characteristic features and progression during reposition of a patient with bilateral nystagmus inversion and speculated its mechanisms. Key Words : Positional vertigo, Semicircular canal, Diagnosis, Nystagmus

Original Articles

A Clinical Significance of AAO-HNS guidelines for Meniere's Disease: Jun Ho Lee, Yun Hoon Choung, Keehyun Park, Min Jung Cho, Jinseok Lee, Yong Ro Yoon, Yun Tae Kim; J Korean Bal Soc. 2005;4(1):26-32.

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Abstract PDF: Background
and Objectives :The guidelines for Meniere's disease recommended from the Committee on Hearing and Equilibrium of the American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS) in 1995, provided a basis for reporting results of the treatment used in Meniere's disease. However, these guidelines are sometimes not all inclusive and appropriate for management and reporting for some patients clinically considered having Meniere's disease. The objectives of this study is to review and analyze the symptoms, vertiginous episodes, audiometry, vestibular function test and results of the treatment in Meniere's disease and to evaluate the significance of AAO-HNS guidelines. Materials and Method : This study consisted of the patients with Meniere symptoms who visited the Dizziness Clinic of Ajou University Hospital between 1994 and 2001 were included in this study. The characteristics of dizziness (duration, frequency, and episodes), pure tone audiometry, vestibular function tests, and treatment results were carefully analyzed according to AAO-HNS guidelines.
Results
: Of 550 patients with Meniere symptoms, 198 patients were in the criteria for Meniere's disease. They were classified to 75 (37.9%) of the “definite”, 120 (60.6%) of the “possible”, and only 3 (1.5%) of the “probable”. In the “definite” group, the pure tone average (PTA) was 54.3 dB and canal paresis (CP) was showed in 33 patients (44%) with a mean CP of 53.6%, and the peak and descending types of the pure tone audiogram were dominant (62%). In the “possible” group, the PTA was 19.4dB and CP was found in 30 patients (25%) with mean CP of 50.1%.
Conclusion
: Even though AAO-HNS guidelines for Meniere's disease are helpful for communication between doctors, they should be considered to have limitations for the diagnosis and treatment in clinical practices.

Reliability of history taking in the diagnosis of benign paroxysmal positional vertigo: Byung Kun Kim, Hee Joon Bae, Ja Seong Koo, Oh Hyun Kwon; J Korean Bal Soc. 2003;2(2):187-190.

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Abstract PDF: Background
and Objectives: Patients with benign paroxysmal positional vertigo (BPPV) usually have typical history. They usually complain of vertigo that lasting a few seconds to a minute. It usually occurs in the morning after awaking and provoked by typical positional change such as head turning, sitting, and lying down. However, some patients may describe their vertigo in a rather atypical way, so there is no absolute reliability of a diagnosis based on history taking. To evaluate the reliability of a diagnosis based on history taking, we performed prospective studies. Materials and Methods: We obtained structured history from all the patients with BPPV. Total of 408 patients were diagnosed as having BPPV. The diagnosis was based on typical findings of vertigo and nystagmus by Dix-Hallpike maneuver and head turning in supine position.
Results
Duration of vertigo was more than 10 minutes in 22% of patients. Position-precipitating factors were not spontaneously reported by 37%. 16% of patients complained non-spinning vertigo. 38% of patients could not tell the side to which the spell occurs. In 83 cases (20%), it was impossible to diagnose BPPV based upon a typical history.
Conclusion
We conclude that non-paroxysmal, non-positional vertigo dose not rule out BPPV. The provocation test is mandatory in those complaining of dizziness regardless of history since BPPV can be quickly diagnosed by provocation test and easily treated.

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