RECURRENT VERTIGO

Timothy C. Hain, MD  • Content last updated: August 23, 2020

There are a substantial number of persons who have periodic vertigo -- usually every 6 months or thereabouts, without hearing changes. Conditions that can be triggered at will - -such as a static BPPV, or a static superior canal dehiscence -- are not included -- the recurrence has to be unpredictable.

This diagnosis and treatment can be difficult - -as we often don't have any good way to separate them out, other than drug trials, it can take a long time to exhaust the repertoire of medications.

Here we will briefly discuss their differential diagnosis. For the most part, these patients are diagnosed as having recurrent versions of conditions that are intrinsically recurrent conditions - -such as migraine.

  1. Benign recurrent vertigo (BRV)
  2. BPPV (recurrent)
  3. Cyclic vomiting
  4. Hydrops without hearing changes.
  5. Migraine associated vertigo
    1. Benign Paroxysmal Vertigo of Childhood
  6. Meniere's disease
  7. Vestibular Neuritis
  8. Stroke and TIA

Benign Recurrent Vertigo (BRV)

This condition is mainly used by clinicians as a "wastebasket" for conditions that don't fit any of the criteria outlined above (Moretti et al, 1980). It is difficult to separate from cyclic vomiting (see later). There is some recent evidence that it may be an entity by itself (Oh et al, 2001; Lee et al, 2006). There is also evidence for it being a migraine variant. Perhaps both are true in some patients. We favor treating BRV in adults with migraine prevention medications, and in particular verapamil.

BPPV

BPPV is a common condition that often recurs, within a year of the first bout. Typically there are no hearing symptoms. BPPV is more common in persons with migraine and Meniere's disease. BPPV is mainly treated with maneuvers.

Cyclic vomiting -

This is a vertigo syndrome, without hearing changes, dominated by vomiting. There are some variants without vertigo too. There is no "litmus test" for cyclic vomiting. Like BRV, It is usually considered a migraine variant. We favor using verapamil and strong antiemetics as treatment for this condition.

Hydrops

This is a laboratory diagnosis, defined by a positive ECochG lacking the full criteria for Meniere's disease. Some investigators feel that migraine can cause hydrops. Conventional treatment is the same as for Meniere's disease. There seems to be very little interest in Hydrops.

Meniere's disease.

Meniere's disease is another disorder which is common enough to be troublesome (about 0.2% of the population), and lacks a definitive pathway to diagnosis. In the past, persons without hearing changes but who had episodic vertigo were labeled "vestibular meniere's". Then, it was pointed out that about 80% of these persons had migraine (only 10% of the population has migraine), and medical opinion changed so that the same group of people were labeled "MAV" (see below). (Rasekh and Harker, 1992).

Nevertheless, this train of logic is not entirely valid as lacking a definitive method of "diagnosing" Meniere's or migraine, the possibility for error is there. In fact, if one accepts that migraine can cause the pathological findings of menieres disease (ECochG), there is no reasonable method of telling Migraine and Meniere's apart.

Migraine associated vertigo. (MAV)

10% of the population has migraine, and about 2/3 of those have dizziness. There is no definitive test for MAV. There is a large repertoire of treatments for MAV.

Vestibular Neuritis.

Fortunately, in the great majority of cases (at least 95%) vestibular neuritis it is a one-time experience. Rarely the syndrome is recurrent, coming back year after year. Treatment is usually symptomatic.

Stroke and TIA

Circulation disturbances can cause episodic vertigo (Fischer et al, 1967). Treatment is aimed at maintaining circulation.

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