Practice Parameter: Therapies for benign paroxysmal positional vertigo (an evidence-based review): [RETIRED]

Fife, Terry D.; Iverson, D. J.; Lempert, Thomas; Furman, Joseph M.; Baloh, Robert W.; Tusa, Ronald J.; Hain, Timothy C.; Herdman, Susan J.; Morrow, Monica; Gronseth, Gary S.

doi:10.1212/01.wnl.0000313378.77444.ac

Cited by 355 publications

(377 citation statements)

References 33 publications

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“…Those with BPPV are probably overimaged and overprescribed antivertigo medication at an estimated cost of more than $2,000 per patient. 54 Vestibular sedatives are ineffective 14 and potentially harmful, 15 but may be continued for months or years by primary physicians once initiated. 35 Use of medications in BPPV is associated with failure to provide proven treatment (canalith repositioning), 14,35 which, in turn, may increase the risk of falls and depression, especially among older patients.…”

Section: Discussionmentioning

confidence: 99%

“…As part of the NHAMCS protocol, trained hospital staff members gather data from ED visit records during a randomly assigned 4-week data period for each Canalith-repositioning maneuvers Proven benefit 25,26 and recommended 14,15,27 Not indicated Corticosteroids Not indicated Proven benefit [28][29][30] and recommended 31,32 Vestibular sedatives Ineffective 14,15,33,34 and potentially harmful from exacerbation of balance disturbance 5,13,15 or delay in repositioning maneuvers 5,15,35 Standard treatment 8,17,20,32,36 APV = acute peripheral vestibulopathy; BPPV = benign paroxysmal positional vertigo.…”

Section: Study Protocolmentioning

confidence: 99%

“…10, BPPV can be confidently diagnosed at the bedside, 10,14,15 while APV sometimes requires advanced diagnostic tests such as neuroimaging by magnetic resonance imaging (MRI) to exclude stroke. 22,[37][38][39] BPPV is cured by bedside physical maneuvers, 14,15,25 while APV treatment is focused on mitigating symptoms and vestibular damage through early pharmacotherapy. 29 Agents recommended in APV include antiemetic and vestibular suppressant drugs, along with corticosteroids, with or without antiviral treatments.…”

mentioning

confidence: 99%

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Disconnect Between Charted Vestibular Diagnoses and Emergency Department Management Decisions: A Cross‐sectional Analysis From a Nationally Representative Sample

Newman‐Toker

Camargo

Hsieh

et al. 2009

Academic Emergency Medicine

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Objectives: The most common vestibular disorders seen in the emergency department (ED) are benign paroxysmal positional vertigo (BPPV) and acute peripheral vestibulopathy (APV; i.e., vestibular neuritis or labyrinthitis). BPPV and APV are two very distinct disorders that have different clinical presentations that require different diagnostic and treatment strategies. BPPV can be diagnosed without imaging and is treated with canalith-repositioning maneuvers. APV sometimes requires neuroimaging by magnetic resonance imaging (MRI) to exclude posterior fossa stroke mimics and should be treated with vestibular sedatives and corticosteroids. We sought to determine if emergency physicians (EPs) apply best practices to diagnose and treat these common vestibular disorders.Methods: This was a cross-sectional study of ED visits from the National Hospital Ambulatory Medical Care Survey (NHAMCS). A weighted sample of U.S. ED visits (1993ED visits ( -2005 was used. Patients at least 16 years of age who were given a final ED diagnosis of BPPV (International Classification of Diseases, 9th Revision [ICD-9], 386.11) or APV (ICD-9 386.12 or 386.3x) comprised the study population. The frequency of imaging and drug therapy in those diagnosed as BPPV or APV versus controls was the main outcome measure.Results: A total of 9,472 dizzy patient visits were sampled over 13 years (weighted estimate 33.6 million U.S. ED visits over that period). A weighted estimate of 2.5 million patients (7.4%) were given a vestibular diagnosis, mostly BPPV (weighted 0.2 million) or APV (weighted 1.9 million). Patients given BPPV (19%) and APV (19%) diagnoses were more likely to undergo imaging (all by computed tomography [CT]) than controls (7%; p < 0.001). Patients given BPPV (58%) and APV (70%) diagnoses were more likely to receive meclizine than controls (0.1%; p < 0.001). Corticosteroid administration was rarely documented (2% BPPV, 1% APV).Conclusions: Patients given a vestibular diagnosis in the ED may not be managed optimally. Patients given BPPV and APV diagnoses undergo imaging (predominantly CT) with equal frequency, suggesting overuse of CT (BPPV) and probably underuse of MRI (APV). Most patients diagnosed with BPPV are given meclizine, which is not indicated. Specific therapy for APV (corticosteroids) is probably underutilized. Educational initiatives and clinical guidelines merit consideration.ACADEMIC EMERGENCY MEDICINE 2009; 16:970-977 ª

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Section: Discussionmentioning

confidence: 99%

Section: Study Protocolmentioning

confidence: 99%

mentioning

confidence: 99%

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Disconnect Between Charted Vestibular Diagnoses and Emergency Department Management Decisions: A Cross‐sectional Analysis From a Nationally Representative Sample

Newman‐Toker

Camargo

Hsieh

et al. 2009

Academic Emergency Medicine

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“…A supine roll test (Supplemental Figure, available online at http://www. mayoclinicproceedings.org) 4,5 should be performed from the supine position by turning the head 90 degrees to the right and then to the left. Nystagmus elicited in hc-BPPV is horizontal and changes direction depending on which ear is down.…”

Section: Discussionmentioning

confidence: 99%

“…If all positional testing results are negative but the history suggests BPPV, it is more useful to repeat positional testing another day than to order an MRI. Several treatment options exist for hc-BPPV, the simplest of which is the Lempert (barbecue roll) maneuver 4 : With the patient supine and the affected ear down, the head (and body as required) is rotated in 90-degree increments toward the healthy side, holding each position for 10 to 30 seconds, until the patient makes a full circle with the affected ear down again. The patient is then simultaneously returned to supine face up and rapidly sat up.…”

Section: Discussionmentioning

confidence: 99%

Clinical pearls in neurology

Watson¹,

Litin

Bundrick³

2015

Disease-a-Month

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Correct Diagnosis for the Proper Treatment of Acute Vertigo—Putting the Diagnostic Horse Before the Therapeutic Cart

2022

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This issue of JAMA Neurology includes a methodologically rigorous systematic review and meta-analysis examining the efficacy of benzodiazepines and antihistamines in patients with acute vertigo. 1 Hunter and colleagues 1 chose an important, common clinical problem, systematically searched for relevant evidence, and then assessed the studies for both quality and risk of bias. Their primary outcome was symptom control of vertigo at 2 hours measured by a visual analog score. Secondary outcomes included symptom control at later time points. Symptom control is clearly an important patient-centric outcome; therefore, their study is relevant and timely.Hunter and colleagues 1 found that antihistamines were superior to benzodiazepines at 2 hours but not at 1 week or 1 month. Importantly, as the authors themselves acknowledge, we do not know if the statistically significant difference in self-rated symptom severity is clinically meaningful. Of the 16 studies analyzed, 9 of them gave the vestibular suppressant for "1 week to 2 months." 1 This duration of medication was in the setting of clinical trials; however, in real-life practice, patients often continue treatment with vestibular suppressants for far longer periods of time. 2,3 Of course, correct treatment of acute vertigo depends on first making a correct diagnosis-something that cannot necessarily be taken for granted. It is worth noting that Hunter et al 1 included studies of patients with acute vertigo of any cause. However, comparing symptomatic treatments for patients with acute vertigo without first determining a specific central or peripheral vestibular diagnosis ignores an enormous body of clinically relevant literature that supports disease-specific treatment. Imagine 3 emergency department (ED) patients with isolated acute vertigo or dizziness. One has typical benign paroxysmal positional vertigo (BPPV), one has vestibular neuritis, and the third has an ischemic cerebellar stroke. The study by Hunter et al 1 shows that antihistamines are more effective than benzodiazepines at controlling acute symptoms, but that is only 1 component of best management. Clearly, the ideal strategy would be to begin with a correct diagnosis, then treat accordingly in disease-specific fashion: (1) canalith repositioning maneuver for BPPV, (2) corticosteroids plus short-term (ie, 3-5 days) vestibular suppressants (Hunter and colleagues 1 would say antihistamines) and early vestibular rehabilitation for vestibular neuritis, and (3) dual antiplatelet therapy as emergent secondary prevention (or other appropriate acute stroke treatment) for the patient with posterior circulation ischemia.

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Practice Parameter: Therapies for benign paroxysmal positional vertigo (an evidence-based review): [RETIRED]

Abstract: AAN ϭ American Academy of Neurology; BPPV ϭ benign paroxysmal positional vertigo; CONSORT ϭ Consolidated Standards of Reporting Trials; CRP ϭ canalith repositioning procedure; NNT ϭ number needed to treat.

Cited by 355 publications

References 33 publications

Disconnect Between Charted Vestibular Diagnoses and Emergency Department Management Decisions: A Cross‐sectional Analysis From a Nationally Representative Sample

Disconnect Between Charted Vestibular Diagnoses and Emergency Department Management Decisions: A Cross‐sectional Analysis From a Nationally Representative Sample

Clinical pearls in neurology

Correct Diagnosis for the Proper Treatment of Acute Vertigo—Putting the Diagnostic Horse Before the Therapeutic Cart

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