Neurological update: dizziness

Abstract

The diagnosis and management of vertigo remains a challenge for clinicians, including general neurology. In recent years there have been advances in the understanding of established vestibular syndromes, and the development of treatments for existing vestibular diagnoses. In this 'update' I will review how our understanding of previously "unexplained" dizziness in the elderly is changing, explore novel insights into the pathophysiology of vestibular migraine, and its relationship to the newly coined term 'persistent postural perceptual dizziness', and finally discuss how a simple bedside oculomotor assessment may help identify vestibular presentations of stroke.

Consciously processing balance leads to distorted perceptions of instability in older adults

“…Chronic dizziness is often attributable to specific neurological, cardiovascular or vestibular dysfunction. However, in at least 50% of cases in older adults, dizziness cannot be explained through traditional neurological or neuro-otological testing [6][7][8]. This does not necessarily mean that neurological or neuro-otological dysfunction is absent, but rather that symptoms of dizziness cannot be readily attributed to such dysfunction using currently available clinical tests.…”

“…In the case of Persistent Postural-Perceptual Dizziness (PPPD), a newly defined disorder of functional dizziness that mostly affects middle-aged adults, recent work suggests that attentional (and related neuro-cognitive) factors may underpin dizziness symptoms that do not present a clear neurological or neuro-otological basis [6,[9][10][11][12][13]. Specifically, it has been suggested that PPPD symptoms may be caused by an anxiety-related preoccupation with consciously processing balance [6,[9][10][11][12][13]. Such hypervigilance is purported to lead to greater awareness of (otherwise subconscious) balance sensations, eliciting a scaling 'mismatch' between perceived and actual postural movements.…”

“…The present work aimed to scrutinise the relationship between fall-related anxiety, conscious processing of balance, and symptoms of dizziness in older adults. Specifically, we sought to experimentally induce attentional factors implicated in existing models of PPPD (anxiety-related conscious processing of balance [6,[9][10][11][12][13]) in a cohort of asymptomatic older adults and evaluate associated changes in perceived instability and postural control. An asymptomatic cohort was selected to isolate the effects of attentional factors on dizziness symptoms, independent from vestibular or neurological dysfunction.…”

A Relationship Between Unexplained Dizziness and Beta-amyloid Plaques Among Older Adults – Mayo Clinic Longitudinal Study of Aging

“…It also includes a lack of uniform criteria for classi cation and de nition of dizziness or lightheadedness in the medical records. However, we believe that 'unexplained' dizziness or lightheadedness may indicate functional dizziness, also known as psychogenic dizziness or persistent postural-perceptual dizziness (Kaski, 2020). Although the exact pathophysiology of functional dizziness is not yet clear, benign paroxysmal positional vertigo, vestibular migraine, and cerebral small vessel disease, anxiety disorders were the most contributing factors (Kaski, 2020).…”

Functional neurological disorders in personal injury

“…Rarely, dizziness is due to posterior circulation stroke (or brain stem trauma), and bedside tests can be used in the emergency setting to distinguish between central and peripheral causes of vertigo. 39 The symptoms and signs of benign paroxysmal positional vertigo (BPPV) are characteristic: vertigo after a brief latency, provoked by head movement and of a duration usually less than a minute, diagnosed by the presence of symptoms and rotatory nystagmus on provocation tests (side lie test or Dix-Hallpike) and cured by particle repositioning manoeuvres (Semont or Epley, respectively). Post-trauma, however, BPPV may involve uncommon or multiple canals, 40 making it more difficult to diagnose and treat.…”