Benign Recurrent Vertigo (BRV)

Timothy C. Hain, MD •Page last modified: September 4, 2021 • You may also be interested in our many other pages on migraine on this site

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

BRV, probably a vertiginous migraine aura without much headache, was described first by Slater (1979). Slater's observations have been affirmed 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 (2009), 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). As recurrent BPPV and BRV are difficult to tell apart, perhaps they are right. 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), but this is certainly still arguable.

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 as well. Of course, all diagnoses based on symptoms alone (which includes most of psychiatry) would fall into this category.

The biggest problem with BRV is separating it from recurrent BPPV. Neither of them have any entirely specific features that might distinguish them from one another, and certainly the two are always a differential diagnosis for the other. One might imagine, for example, that a patient with recurrent positional vertigo might be designated BRV if they had migraines as well (more common in women), and recurrent BPPV if they didn't also have migraines. We would be more prone to diagnose recurrent BPPV if there was strong, unilateral classic (i.e. PC type) nystagmus. We would be more prone to diagnose BRV if PT had failed, and there was a horizontal direction changing type positional nystagmus, or if there were also migraneous features such as light sensitivity during the dizziness.

Genetics of BRV-- a little confusing as of 2021

Oh et al (2001) reported on the families of 24 patients with BRV and suggested it might be inherited.

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.

Xu et al (2021) reported "an insertion variant rs113784532 (frameshift causing truncation) in the neural cadherin gene PCDHGA10 (protocadherin-gamma A10) is an exceedingly strong candidate". This gene is on chromosome 5.

Somewhat similar episodic ataxia can be associated with mutations in chromosome 19, which also contains the locus for familial hemiplegic migraine.

Similar entities -- not necessarily different.

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 in migraine with dizziness, 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. If there is some ambiguity with BPPV (nearly always), then there is usually also an attempt at vestibular physical therapy for positional vertigo.

For both the vertigo and vomiting, the usual cocktail of medications including:

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.

It has also been reported that vit-D supplementations has a positive effect on recurrent BPPV (presumably not BRV from migraine, but who can tell the difference ?)

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.

Bottom line:

Recurrent BPPV (due to crystals) and BRV (a migraine variant) have no strong distinguishing features, and when one cannot "cure" BPPV with maneuvers, a trial of migraine treatment may be worth considering.


References: