BPPV and MIGRAINE

Speaker Disclosure

Diagnosis and Treatment of the Two Most Common Causes of Dizziness Scott K Sanders, MD, PhD Coalition of Advanced Practice Nurses of Indiana Annual Convention

No Financial Relationships to Disclose

April 11, 2015

Format of Presentation

Inner Ear Anatomy

• Brief Background • Anatomy • Recording eye movements • BPPV • Symptoms • Diagnosis of Multiple BPPV Types • Treatment • Migraine • Symptoms • Treatment

Inner Ear Anatomy

Infrared Video-oculography

Left-beat Nystagmus

BPPV Benign Paroxysmal Positional Vertigo

Positional Vertigo of BPPV • First described by Barany in 1921 • 1952: Dix and Hallpike described the test (Dix-Hallpike position) which helps identify BPPV as the etiology of episodic vertigo • 1992: John Epley describes the canalithiasis theory of BPPV and the canalith repositioning procedure

BPPV • Due to otoconia (canaliths, crystals, rocks) from the utricle of the inner ear which break free and travel into a semicircular canal • Move in the fluid-filled semicircular canal with changes in head position, mitigated by gravity • Results in abnormal nerve stimulation causing nystagmus • Results in brief vertigo associated with changes in head position • Laying down, getting up from, or rolling over in bed • Looking up or down, bending over

Epley a “quack” • John Epley, MD, ENT from Portland, OR • 1980 ENT meeting demonstrated his “maneuver” - audience walked out • 1983 submitted journal article to Otology for publication rejected “defied established theory” • 1992 journal article published in JAAO - 30 patients suffering BPPV with 100% cure rate • Despite publication, many doctors rejected his work and local colleagues stopped referring patients for the next several years • Eventually, his “canalith repositioning” maneuver was accepted and became known as the “Epley” maneuver

Otoconia “Crystals”

“Crystals” Displaced into Posterior Canal

Causes of BPPV • Primary or idiopathic (50%–70%) • Dr. Tim Hain “As a rule of thumb, about 50% of dizziness is caused by BPPV by the age of 80”

• Secondary (30%–50%) • Head trauma (7%–17%) • Viral labyrinthitis (15%) • Ménière's disease (5%) • Migraines (< 5%) • Inner ear surgery (< 1%)

Types of BPPV • Posterior Canal (PC) • Horizontal Canal (HC)

Posterior Canal (PC) BPPV

• Anterior Canal (AC) • Cupulolithiasis (‘stuck crystals’)

Checking for PC BPPV • Dix-Hallpike position • Start with sitting upright on a table • Turn head 45 degrees to the right or left • Lay back quickly with neck extended 30 degrees below horizontal

• If unable, try side lying position

Right Dix-Hallpike Position

Dix-Hallpike Position for Left PC BPPV

Dix-Hallpike Position for Right PC BPPV

Watch for “unwinding”
 nystagmus upon returning to sit

Treatment of PC BPPV

(Modified) Epley Maneuver

• Canalith Repositioning Maneuvers (CRM)

Turn head to left and move opposite direction for Left PC BPPV

• (modified) Epley

Shown for Right PC BPPV

• Semont • Half Somersault • NOT vestibular suppressant medications (meclizine, diazepam, phenergan) or habituation exercises (CawthorneCooksey, Brandt-Daroff)

(Modified) Epley Maneuver

Semont Maneuver for Right PC BPPV

Shown for Right PC BPPV

Turn head to left and move opposite direction for Left PC BPPV

Opposite for left PC BPPV

Half Somersault for Right PC BPPV

The Goal of CRMs

Audiology & Neurotology 2012;2:16-23

• Put the “crystals” back in the utricle

Head turn to left elbow in “C” for Left PC BPPV

• Enzymes (dark cells) that dissolve loose “crystals”

Checking for HC BPPV • Lay supine with neck flexed 30 degrees • Turn head or body right, then left

Horizontal Canal (HC) BPPV

• If otoconia in horizontal canal, see horizontal nystagmus • Geotropic • R-beat in head Right • L-beat in head Left

HC Testing Position

Can also test HC by lying on back with head turn to right or left

Left Horizontal Canal BPPV

Determining “Side” of HC BPPV • Ewald’s second law - excitatory stimuli produce a greater response than inhibitory stimuli • With HC BPPV • RIGHT EAR - excitatory response occurs in the right HC when the right ear is down and inhibitory response occurs in the right HC when the left ear is down • LEFT EAR - excitatory response occurs in the left HC with the left ear is down and inhibitory response occurs in the left HC when the right ear is down • Therefore, the “side” with loose otoliths in the HC elicits the greater nystagmus when turned toward the ground

Treatment for HC BPPV

Why is Choosing the Correct Side Important? • With Left HC BPPV, treatment is to roll to the Right • With Right HC BPPV, treatment is to roll to the Left • Rolling the wrong way could push the “crystals” against the cupula where they could become stuck (“cupulolithiasis”)

Lempert Roll for Right HC BPPV

• Head/Body Roll Away from Affected Ear • (Baloh)-Lempert Roll • BBQ Roll

Roll opposite direction for Left HC BPPV

• Log Roll

• Alternatives • Vannucchi-Asprella • Gufoni • Appiani (patient unable to lay on back or stomach)

Lempert Roll for Right HC BPPV

BPPV - Posterior vs Horizontal Right Posterior Canal BPPV

Left Horizontal Canal BPPV

Hallpike Position Right

Supine Head Right, then Head Left

Roll opposite direction for Left HC BPPV

BPPV Summary Canal

Head Position

Nystamus

Canalith Repositioning Maneuver

Posterior

Hallpike

Upbeat Rotational

modified Epley, Semont

Horizontal

Supine

Right-beating in Head Right and Leftbeating in Head Left

Lempert Roll

Anterior

Hallpike

Downbeat Rotational

modified Epley from deep Hallpike

Canalithiasis

Cupulolithiasis

Cupulolithiasis

Cupulolithiasis • Cupula becomes gravity-sensitive • Difference in characteristics from Canalithiasis •Longer-lasting •More resistant to repositioning maneuvers - only 50% success

Checking for Cupulolithiasis - HC • Lay supine with neck flexed 30 degrees • Turn head or body right, then left • Apogeotropic nystagmus •

Left-beating with head to the right

•

Right-beating with head to the left

• Greater slow phase velocity nystagmus ear up is the involved ear

Cupulolithiasis

Choosing Correct Side

Treatment of Cupulolithiasis - HC Goal in treatment: Convert to Canalithiasis •

Forced prolonged positioning – unaffected side 12 hours

•

Head thrusts toward unaffected ear repeated 10x

•

Vannucci-Asprella - 4 step maneuver repeated 10x

•

Inverted Gufoni (lie to affected side nose up)

BPPV Recurrence More About BPPV

“Benign paroxysmal positional vertigo and its management”

•

30% in first year, then 15%/year

•

50/50 chance of recurrence at 3 years

•

Home canalith repositioning instructions

Management of BPPV

• Med Sci Monit, 2007 Jun • 204 patients • Posterior Canal - 80% • Horizontal Canal - 9.5% • Anterior Canal - 3% • Bilateral Posterior Canal - 5% • Multicanal - 2.5% • Appropriate repositioning maneuver 92% success rate

Med Sci Monit, 2007 Jun – CRM (such as Epley maneuver) 92% success rate • No longer should be using medications (no meclizine or diazepam or phenergan) • No longer should be performing habituation exercises (Brandt-Daroff, Cawthorn-Cooksey)

CRM Failure

Post-CRM Restrictions Not Necessary

•

•

•

J Otolaryngol 1996; 25:121-5

Vestibular habituation exercises (Brandt-Daroff; Cawthorne-Cooksey) - next to last case scenario

•

Otolaryng Head Neck Surg 2000; 122:440-4

•

Rev Bras Otorrinolaringol 2005 Nov-Dec; 71(6): 764-8

Surgical canal plugging - last case scenario

•

Eur Arch Otorhinolaryngol (2005) 262:408-11

•

Otology and Neurology 29(5) August 2008:706-9

•

Neurology 2008; 70:2067-74

•

Otolaryng Head and Neck Surg. Feb1, 2010 v 142(2); 155-9

Case Case

• 52 year old woman who has started sleeping with her head elevated on 3 pillows because she usually develops vertigo laying down in bed • Vertigo lasts 10-15 seconds and may also occur when she gets up from bed, looks up or looks down • She was evaluated in the ER and given meclizine, but this just made her sleepy

Case Examination showed transient upbeat rotational nystagmus lasting 15 seconds, when placed in the left Hallpike position

Case • She underwent a modified Epley maneuver, but continued to experience positional vertigo • Repeat Hallpike positioning to either side was negative for BPPV of the posterior canal

Case - Body R, then Body L

Case • What happened? • Does the patient need an MRI? • What is the diagnosis?

Case • May have had multi-canal BPPV (both PC and HC canal on the left) at presentation • OR, during the modified Epley maneuver, the otoliths went from the PC to the HC - Canal Conversion

Migraine and Dizziness

• 15% occurrence • Tx: Perform Lempert roll to the right

“Approximately 60-80% of patients who

“Migraine simply causes more vertigo than any other condition” - Timothy Hain, MD, PhD

experience recurrent vertigo without hearing loss have migraines” - Brandtberg and Furman, 2005

Migraine-associated Dizziness

• Migraine-related dizziness

• The #1 cause of dizziness

• “gigantic topic”

• Under-recognized • Often have mild or no concurrent headaches, but usually have a headache history (‘sinus headache’ = migraine)

Migraine-associated Dizziness Symptoms • Dizziness that is often difficult to describe • Morning predominance of symptoms • Wide range of duration

AAO-HNS meeting 2011

• Grocery shopping is difficult (big box stores) • May have light and/or noise sensitivity • Usually have a history of headaches, but often no concurrent headaches

• Visual motion sensitivity is common

• “huge as a cause of dizziness” • “dominates our practice” • “15 times more common than Meniere’s”

Migraine-associated Dizziness Diagnosis • Rule out other causes - vestibular function testing usually adequate if neurologic exam and hearing is normal Treatment • Eliminating any triggers • Preventative medications

Migraine-associated Dizziness

Non-food Triggers

Treatment • Identification and modification/ elimination of triggers • Medications • Tricyclic • amitriptyine* • nortriptyline* • SSRI • venlafaxine

• Anti-hypertensive • verapamil* • propranolol • Anti-seizure • valproic acid* • topirimate* • gabapentin Prognosis - Excellent!

• Inadequate sleep • Weather changes • Hormone changes • Stress • Allergies

Food Triggers

Tricyclic Antidepressants nortriptyline - 10, 25, 50, 75, 100 mg

• MSG

amitriptyline - 10, 25, 50, 75, 100 mg

• Nutrasweet

• Take once daily 1-2 hours before bedtime

• Packaged meats

• Side effects

• Nuts • Alcohol

Anti-Hypertensive

• 3 “D”s - Drowsiness (amitrip > nortrip), Dry mouth, weird Dreams • other less common - weight gain, heartburn, palpitations, moodiness/angry

Anti-epileptics valproic acid (ER) 125, 250, 500 mg

verapamil (SR) 120, 180, 240, 300, 360 mg

• Take once daily

• Take once daily at breakfast

• Side effects - weight gain, hair loss, tremor, drowsiness, nausea

• Side effects

• Avoid in women of child bearing age (neural tube defects)

• constipation • rarely peripheral edema, palpitations

Monitoring Medication Treatment

topirimate (has ER form available now) 25, 50, 100, 200 mg • Take twice daily • Side effects - paresthesias, taste alteration, weight loss, confusion (“dopamax”), reduced sweating, kidney stones - rare angle closure glaucoma

Neuhauser criteria for migrainous vertigo (2005) • Recurrent vestibular symptoms

• Dosing - start low and go slow

• Migraine headache meeting criteria (current or previous)

• Improvement delayed for 3-4 weeks after starting and after dose changes

• At least one of the following migrainous symptoms during at least two of the attacks

• If not working, try alternative • If no symptoms for 6 months, consider tapering/stopping

• migraine-type headache • visual or other aura • photophobia • phonophobia • Other causes ruled out

Migraine-associated Vertigo (MV) - in Curr Pain Headache Rep, 2007 June • “A strong association exists between vertigo and migraine with MV being the most common cause of spontaneous (nonpositional) vertigo” • “Symptoms can be quite variable among patients and within individual patients over time, creating a diagnostic challenge”.

Concluding Remarks

• “MV generally presents with attacks of spontaneous or positional vertigo lasting seconds to days with associated migrainous symptoms”. • “…proper studies of optimal MV management are just beginning”.

BPPV

BPPV Overdiagnosed • Look for spontaneous nystagmus (vestibular neuritis/labyrinthitis)

• Diagnose (R/L) side and affected semicircular canal(s) • Treat with CRM (not meclizine or habituation exercises)

• Be certain that the provoked nystagmus fits the characteristic features and is of the correct type for the head position • 2-3 second latency • 10-15 second duration • upbeat rotational for Dix-Hallpike - PC • horizontal for head supine/right/left - HC

Other Causes of “Positional” Vertigo

Migraine is #1

• *Migraine • Multiple Sclerosis • Arnold-Chiari Malformation • Drug Effects • Cerebellar Stroke or Degeneration • Intracranial Tumor • Neurovascular Compression of CN VIII • Uncompensated Unilateral Vestibular Loss

If BPPV is unlikely/ruled out and there is no hearing loss or neurologic symptoms in the setting of recurrent dizziness/vertigo - ALWAYS consider migraine, even if no headaches

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