Benign Recurrent Vertigo (BRV)

Timothy C. Hain, MD •Page last modified: August 23, 2020 You may also be interested in our many other pages on migraine on this site

Benign recurrent vertigo of adults -- also see Cyclic Vomiting recurrent vertigo.

BRV, essentially a vertiginous migraine aura without much headache, was described first by Slater (1979) but his observations have been confirmed by others (e.g. Lee et al, 2002; Cha et al, 2009). It consists of spells of vertigo, which can include tinnitus, but without hearing loss (were hearing loss allowed, this disorder would become very difficult to distinguish from Menieres disease ). Vertigo lasts from minutes to hours. According to Cha et al, sensory amplifications such as photophobia or auditory symptoms were uncommon in patients without headache, but were common in patients with headache. Not all authors agree that BRV is caused by migraine however, and Leliever and Barber suggested that it is caused by peripheral vestibular lesions (Leliever and Barber, 1981). At this writing (2012), this idea seems to have been discarded. Brantberg and Baloh (2011) reported that the vertigo in BRV overlaps substantially with vertigo in Meniere's. They also noted that many patients with BRV never develop headaches. The scanty literature on BRV generally supports the idea that it is a migraine variant (Kitamura et al, 1990)

Kental and Pyykko (1997) suggested that BRV might be a "artificial diagnosis". They used this term to describe conditions described by exclusion of other diagnoses. They are certainly correct here. This label, which we call a "committee diagnosis", might also be reasonably applied to Meniere's disease and Migraine. Of course, all diagnoses based on symptoms alone (which includes most of psychiatry) would fall into this category.

Oh et al (2001) reported on a single family with familiar BRV. Lee et al (2006) suggested that BRV is linked to chromosome 22q12, and also suggested that BRV affects 2% of the entire adult population (Lee et al, 2006). We ourselves are dubious that 2% of the population has BRV (this is more than vestibular migraine!), and we alre also dubious that it usually runs in families. So in essence, we are doubtful.

Another example of a similar recurrent vertigo, without headache, attributed to migraine is the Benign Paroxysmal Vertigo syndrome of children, as described in this page under the heading of familial syndromes, where headache does not occur. With respect to timing, Cutrer and Baloh (1992) also observed that dizziness and headaches are not necessarily closely associated. In fact, in their 91 patients, only 5 had a consistent recurring dizziness with headache. In 30%, dizziness was consistently independent of headache. In most, spells sometimes occurred with and sometimes independently.

BRV is nearly identical to cyclic vomiting of adults (CV), but in CV, the vomiting dominates.

In BRV (or CV), a seasonal pattern is common in adults -- with timing (in Chicago) typically being in November.

Case example:

A middle aged woman provided a history of having 1-2 spells per year, of dizziness lasting a day. She called for an urgent appointment. She was "due" for her period, as she was on a birth control pill., and taking the "blanks". The vertigo began when she awoke in the morning. She had taken meclizine and found it just put her to sleep and did not help her dizziness. She did not have any substantial headache. On her exam, she had no nystagmus in the dark, upright. Lying down, she had a complicated positional nystagmus that was right-beating on head left, and downbeating on head right. The nystagmus gradually built up over seconds, and became rather uncomfortable after about 10 seconds. She had a similar downbeating nystagmus, that also built up with her head forward looking down at the floor. The rest of her examination was normal.

Comment: This woman clearly has an objectively verifiable nystagmus, that does not fit into the usual criteria for BPPV of any canal. Her dizziness occured when her estrogen levels were low.

Treatment of Benign recurrent vertigo (BRV) and Cyclic Vomiting (CV)

Treatment of BRV and CV combines symptom management (usually the vertigo or vomiting), and migraine prevention. For both the vertigo and vomiting, the usual cocktail of medications including:

    • anticholinergics(such as meclizine)
    • benzodiazepines (such as valium or lorazepam)
    • dopamine blockers (such as phenergan, or stronger anti-dopamine medications)

This pharmacology is summarized on the emesis (vomiting) page. People with either BRV or CV usually keep these drugs close at hand.

The other approach to both BRV and CV is to use migraine prevention medications. This has been little studied, but in theory, medication such as nortriptyline, verapamil, and any of the anti-seizure migraine medications might work. The author of this page has had the most experience with verapamil, which is often very successful in preventing BRV.

Emerging treatments ?

So far, while the CGRP inhibitor class of drugs appear to work well for cluster headache (which can also be seasonal), there is no literature about its use in the seasonal variety of BRV.


References:

  • Brantberg, K. and R. W. Baloh (2011). "Similarity of vertigo attacks due to Meniere's disease and benign recurrent vertigo, both with and without migraine." Acta Otolaryngol 131(7): 722-727.
  • Cha, Y. H., et al. (2009). "Association of benign recurrent vertigo and migraine in 208 patients." Cephalalgia 29(5): 550-555.
  • Kentala, E. and I. Pyykko (1997). "Benign recurrent vertigo--true or artificial diagnosis?" Acta Otolaryngol Suppl 529: 101-103.
  • Kitamura, K. and Y. Kudo (1990). "Benign recurrent vertigo in Japanese." Auris Nasus Larynx 17(4): 211-216.
  • Lee H et al. Migraine and isolated recurrent vertigo of unknown cause. Neurol Res 2002; 24: 663-665
  • Lee, H., et al. (2006). "A genome-wide linkage scan of familial benign recurrent vertigo: linkage to 22q12 with evidence of heterogeneity." Hum Mol Genet 15(2): 251-258.
  • Leliever WC, Barber HO. Recurrent vestibulopathy. Laryngoscope 1981:91:1-6
  • Oh, A. K., et al. (2001). "Familial benign recurrent vertigo." Am J Med Genet 100(4): 287-291.
  • Slater R. Benign recurrent vertigo. J Neurol Neurosurg Psych 42:363, 1979