Association Between Migraine and Benign Paroxysmal Positional Vertigo Among Adults in South Korea

Why is vestibular migraine associated with many comorbidities?

Vestibular migraine (VM) is a usual trigger of episodic vertigo. Patients with VM often experience spinning, shaking, or unsteady sensations, which are usually also accompanied by photophobia, phonophobia, motor intolerance, and more. VM is often associated with a number of comorbidities. Recurrent episodes of VM can affect the patient's emotions, sleep, and cognitive functioning to varying degrees. Patients with VM may be accompanied by adverse moods such as anxiety, fear, and depression, which can gradually develop into anxiety disorders or depressive disorders. Sleep disorders are also a common concomitant symptom of VM, which significantly lower patients' quality of life. The influence of anxiety disorders and sleep disorders may reduce cognitive functions of VM, such as visuospatial ability, attention, and memory decline. Clinically, it is also common to see VM comorbid with other vestibular disorders, making the diagnosis more difficult. VM episodes are relieved but lingering, in which case VM may coexist with persistent postural-perceptual dizziness (PPPD). Anxiety may be an important bridge between recurrent VM and PPPD. The clinical manifestations of VM and Meniere's disease (MD) overlap considerably, and those who meet the diagnostic criteria for both can be said to have VM/MD comorbidity. VM can also present with positional vertigo, and some patients with VM present with typical benign paroxysmal positional vertigo (BPPV) nystagmus on positional testing. In this paper, we synthesize and analyze the pathomechanisms of VM comorbidity by reviewing the literature. The results show that it may be related to the extensive connectivity of the vestibular system with different brain regions and the close connection of the trigeminovascular system with the periphery of the vestibule. Therefore, it is necessary to pay attention to the diagnosis of comorbidities in VM, synthesize its pathogenesis, and give comprehensive treatment to patients.

Evaluation and diagnosis of pediatric patients with dizziness

PURPOSE OF REVIEW

Children experiencing dizziness frequently go unevaluated or experience delays in correct diagnosis due to systemic and inherent barriers. While most causes of pediatric dizziness do not involve the peripheral vestibular system, otolaryngologists are frequently consulted for expert opinion. This study offers a broad overview of the leading causes of pediatric dizziness and imbalance to assist otolaryngologists with evaluating and managing this challenging population.

RECENT FINDINGS

Evaluation of children with dizziness should exclude serious central nervous system conditions. Approximately 70% of nonhazardous cases of pediatric dizziness are caused by migraine-related conditions, concussion, or functional disorders. Etiologies for peripheral vestibular dysfunction include inner ear malformations and vestibular disorders more commonly seen in adults. Audiometric and vestibular testing can provide helpful information, although correct diagnosis depends on a detailed history.

SUMMARY

Otolaryngologists should be familiar with the conditions that cause dizziness in children. While most underlying causes are outside their scope of practice, understanding possible etiologies can facilitate correct diagnosis and appropriate management.

Vestibular migraine as a mimic of benign paroxysmal positioning vertigo and Meniere's disease

BACKGROUND

Vestibular migraine (VM) is a common cause of recurrent spontaneous and positional dizziness of varying durations. Short episodes of VM lasting seconds to minutes, triggered by changes in head position can resemble those of benign paroxysmal positioning vertigo (BPPV), while episodes lasting minutes to hours can mimic those of Meniere's disease (MD).

OBJECTIVE

We aimed to compare symptoms and vestibular test results in patients with VM, BPPV and MD, where VM was categorized by episode duration.

METHODS

We compared vestibular, aural and migraine symptoms, as well as cervical and ocular vestibular evoked myogenic potentials and 3D video head impulse tests, in 108 patients: 24 with BPPV, 33 with VM episodes of short duration (<10 min), 29 with VM of medium duration (≥10 min) and 22 with MD.

RESULTS

We found significant overlap in the symptoms of all patient groups, and no significant differences between patients with short and medium VM. Abnormal test results occurred infrequently in all groups.

CONCLUSIONS

Our results confirm significant symptom overlap between BPPV or MD and VM, and suggest that VM mimics other conditions when the episode duration matches the differential diagnosis, rather than because patients with different durations of vertigo have different symptoms.

Effect of Smoking on the Development of Migraine in Women: Nationwide Cohort Study in South Korea

Background

Smoking is known to be a significant risk factor for various diseases. Migraine, a condition requiring careful lifestyle management, currently lacks specific guidelines advocating for smoking cessation as a preventive measure. Although cross-sectional studies have suggested a potential link between smoking and an increased risk of migraine, the findings have been inconsistent and conflicting. To date, there has been no longitudinal study which investigated the effect of smoking on the risk of migraine in a prospective setting.

Objective

This longitudinal study aimed to investigate the impact of smoking on the incidence of migraine in women and examine the modifying effect of menopausal status.

Methods

Using nationally representative National Health Insurance Service (NHIS) data, women aged ≥40 years who participated in national breast cancer screening in 2009 were followed-up until the end of 2019. Baseline data on smoking status (non-, ex-, and current smoker) as well as the duration and amount of cigarette smoking were collected. A Cox proportional hazards regression model was used to examine the independent effect of smoking on the risk of incident migraine after adjusting for demographics, comorbidities, and female reproductive factors. The results were stratified by menopausal status, and an interaction analysis (smoking × menopause) was performed.

Results

In total, 1,827,129 women were included in the analysis. Women with a history of smoking exhibited a higher risk of developing migraine, compared with nonsmokers. Specifically, a higher risk of migraine was observed in women with past (adjusted hazard ratio [HR] 1.044, 95% CI 1.000-1.089) and current cigarette use (adjusted HR 1.050, 95% CI, 1.023-1.079) than in nonsmokers. The effect was greater in premenopausal women (adjusted HR 1.140, 95% CI, 1.108-1.172) than in postmenopausal women (adjusted HR 1.045, 95% CI 1.018-1.073; P<.001). The risk increased with an increased amount of smoking, with a greater association in premenopausal women (P<.001).

Conclusions

Smoking increases the risk of migraine in women, with a dose-dependent relationship. Menopause modifies this effect. Our findings suggest that smoking is an important modifiable risk factor of migraine, with a higher impact in premenopausal women. The interaction between smoking and estrogen may increase the vulnerability of the migraine brain.

Focused Update on Migraine and Vertigo Comorbidity

PURPOSE OF REVIEW

To provide an update on comorbidity of vestibular symptoms and migraine.

RECENT FINDINGS

Multisensory processing and integration is a key concept for understanding mixed presentation of migraine and vestibular symptoms. Here, we discuss how vestibular migraine should be distinguished from a secondary migraine phenomenon in which migraine symptoms may coincide with or triggered by another vestibular disorder. We also have some updates on the diagnostic criteria of vestibular migraine, its pathophysiology, and common approaches used for its treatment. As a common clinical presentation of migraine and vestibular symptoms, vestibular migraine should be distinguished from a secondary migraine phenomenon, in which migraine symptoms may be triggered by or coincide with another vestibular disorder. Recent experimental evidence suggests vestibular symptoms in vestibular migraine are linked to multisensory mechanisms that control body motion and orientation in space.

Adoption of clinical practice guidelines in cases of benign paroxysmal positional vertigo

PURPOSE

Despite being one of the most common types of the peripheral vertigo encountered in clinical practice, benign paroxysmal positional vertigo (BPPV) remains underdiagnosed and undertreated, even in affluent health care systems. The publication of fully updated clinical practice guidelines significantly facilitated the diagnosis and treatment of BPPV. This study evaluates the adoption of the guidelines in our clinical setting and reviews further recommendations for quality-of-care improvement.

METHODS

This retrospective cross-sectional survey included a total of 1155 adult patients diagnosed with BPPV at the biggest tertiary care center in the country during a 5-year period (2017-2021). The data for the first three years (2017-2020) and 919 patients were collected in full, and for the remaining 236 patients (2020-2021) only partially due to the disturbance in referrals caused by COVID-19 pandemic.

RESULTS

The familiarity with and adherence to the published clinical guidelines by physicians judged by patients' charts and our health care database were overall unsatisfactory. The adherence varied from 0 to 40.5% in our sample. The recommendations for making the diagnosis and for repositioning procedure as first-line therapy were followed in only 20-30% of cases.

CONCLUSION

There are large opportunities for improvement in quality of care of BPPV patients. Apart from constant and systematic education at the primary health care level, the health care system may need to adopt more advanced measures of ensuring better adherence to guidelines and subsequent reduction in medical costs.

Management of Migraine-Associated Vestibulocochlear Disorders

Migraine is a chronic neurological disorder that frequently coexists with different vestibular and cochlear symptoms (sudden hearing loss, tinnitus, otalgia, aural fullness, hyperacusis, dizziness, imbalance, and vertigo) and disorders (recurrent benign positional vertigo, persistent postural perceptual dizziness, mal de debarquement, and Menière's disease). Despite evidence of an epidemiological association and similar pathophysiology between migraine and these vestibulocochlear disorders, patients suffering from migraine-related symptoms are usually underdiagnosed and undertreated. Current migraine treatment options have shown success in treating vestibulocochlear symptoms. Lifestyle and dietary modifications (reducing stress, restful sleep, avoiding migraine dietary triggers, and avoiding starvation and dehydration) and supplements (vitamin B2 and magnesium) offer effective first-line treatments. Treatment with migraine prophylactic medications such as tricyclic antidepressants (e.g., nortriptyline), anticonvulsants (e.g., topiramate), and calcium channel blockers (e.g., verapamil) is implemented when lifestyle and dietary modifications are not sufficient in improving a patient's symptoms. We have included an algorithm that outlines a suggested approach for addressing these symptoms, taking into account our clinical observations. Greater recognition and understanding of migraine and its related vestibular and cochlear symptoms are needed to ensure the appropriate diagnosis and treatment of affected patients.

Benign Paroxysmal Positional Vertigo Is Associated with an Increased Risk for Migraine Diagnosis: A Nationwide Population-Based Cohort Study

Previous studies reported an increased risk of benign paroxysmal positional vertigo (BPPV) in patients with migraine. Hence, we aimed to assess the risk of migraine in patients with BPPV. This cohort study was conducted using the Taiwan National Health Insurance Research Database. The BPPV cohort consisted of patients aged <45 years with a diagnosis of BPPV between 2000 and 2009. An age- and sex-matched comparison group free from a history of BPPV or migraine was selected. All cases were followed up from 1 January 2000 to 31 December 2010 or until death or a diagnosis of migraine. The baseline demographic characteristics in both groups were compared using Student's t-test and the chi-square test. Cox proportional hazards regression analysis was used to estimate the hazard ratio for migraine in the BPPV cohort compared with the comparison group after adjustment for age, sex, and comorbidities. Notably, 117 of the 1386 participants with BPPV and 146 of the 5544 participants without BPPV developed migraine. After adjustment for age, sex, and comorbidities, BPPV showed an adjusted hazard ratio indicating a 2.96-fold increased risk of migraine (95% confidence interval: 2.30-3.80, p < 0.001). We found that BPPV is associated with an increased risk of a migraine diagnosis.

Connection between right-to-left shunt and photosensitivity: a community-based cross-sectional study

Background

Hypersensitivity to light is a common symptom associated with dysfunction of the occipital region. Earlier studies also suggested that clinically significant right-to-left shunt (RLS) could increase occipital cortical excitability associated with the occurrence of migraine. The aim of this study was to investigate the relationship between RLS and photosensitivity.

Methods

This cross-sectional observational study included the residents aged 18-55 years living in the Mianzhu community between November 2021 and October 2022. Photosensitivity was evaluated using the Photosensitivity Assessment Questionnaire along with baseline clinical data through face-to-face interviews. After the interviews, contrast-transthoracic echocardiography (cTTE) was performed to detect RLS. Inverse probability weighting (IPW) was used to reduce selection bias. Photosensitivity score was compared between individuals with and without significant RLS using multivariable linear regression based on IPW.

Results

A total of 829 participants containing 759 healthy controls and 70 migraineurs were finally included in the analysis. Multivariable linear regression analysis showed that migraine (β = 0.422; 95% CI: 0.086-0.759; p = 0.014) and clinically significant RLS (β = 1.115; 95% CI: 0.760-1.470; p < 0.001) were related to higher photosensitivity score. Subgroup analysis revealed that clinically significant RLS had a positive effect on hypersensitivity to light in the healthy population (β = 0.763; 95% CI: 0.332-1.195; p < 0.001) or migraineurs (β = 1.459; 95% CI: 0.271-2.647; p = 0.010). There was also a significant interaction between RLS and migraine for the association with photophobia (p_interaction = 0.009).

Conclusion

RLS is associated with photosensitivity independently and might exacerbate photophobia in migraineurs. Future studies with RLS closure are needed to validate the findings.

Trial registration

This study was registered at the Chinese Clinical Trial Register, Natural Population Cohort Study of West China Hospital of Sichuan University, ID: ChiCTR1900024623, URL: https://www.chictr.org.cn/showproj.html?proj=40590.

Persistent Postural Perceptual Dizziness in Episodic Vestibular Disorders

Benign Paroxysmal Positional Vertigo (BPPV), Vestibular Migraine (VM), and Meniere Disease (MD) are among the most common episodic vestibulopathies. Persistent Postural Perceptual Dizziness (PPPD) is a chronic functional vestibular disorder that can arise in patients suffering from one or more of these conditions. We analyzed the role of these vestibular disorders as single or multiple associated comorbidities and as a precipitating condition for PPPD. A total of 376 patients suffering from dizziness with a known history of single or multiple vestibular disorders were preliminarily evaluated. We conducted a careful anamnesis to determine whether the reported dizziness could meet the diagnostic criteria for PPPD. PPPD was diagnosed in 24 cases; its incidence in patients with history of a single comorbidity or multiple vestibular comorbidities was 3.9% and 22.4%, respectively. BPPV, VM, and MD were identified as a precipitating condition in 2.34%, 16.45%, and 3.92%, respectively. BPPV constituted a precipitating condition mainly at the first episode. We observed that the presence of multiple vestibular comorbidities (BPPV, VM, and MD) in patients' clinical history increased the risk of PPPD. VM plays a significant role in representing a precipitating condition for PPPD, both when present individually or in association with the other vestibular disorders.

Examining Migraine as a Predictor of Benign Paroxysmal Positional Vertigo Onset, Severity, Recurrence, and Associated Falls

Introduction: The comorbidity of migraine and benign paroxysmal positional vertigo (BPPV) is well-established, yet the impact of migraine on the BPPV phenotype remains understudied.

Methods: A retrospective analysis of patients at a tertiary dizziness/vertigo clinic diagnosed with BPPV from 2015 and 2020 was conducted. The study's primary outcomes were the age of BPPV onset, Dizziness Handicap Index (DHI), BPPV recurrence, and dizziness-related falls.

Results: In our cohort of 255 BPPV patients, 44.7% had a history of migraine. Those with migraine had an earlier age of BPPV onset than individuals without migraine (60.2 vs. 65.4, p = 0.0018). Migraineurs and non-migraineurs did not differ in their DHI (44.7 vs. 41.6, p= 0.44), recurrence rates (48.3% vs. 40.4%, p= 0.21), and falls (32.5% vs. 37.6%, p = 0.39). Among individuals with horizontal canal BPPV, a higher proportion of migraineurs experienced falls than non-migraineurs (50.0% vs. 6.3%, p = 0.02).

Conclusions: Migraineurs experience BPPV at a younger age than those without migraine. This finding suggests that migraine, which has been shown to cause inner ear damage, predisposes individuals to developing BPPV earlier. Migraine was also associated with a higher rate of falls among patients with horizontal canal BPPV, indicating that a migraine history may impact the phenotype of BPPV.

Association between Benign Paroxysmal Positional Vertigo and Previous Proton Pump Inhibitor Use: A Nested Case-Control Study Using a National Health Screening Cohort

The present nested case−control study evaluated the impact of previous proton pump inhibitor (PPI) prescription on the risk of benign paroxysmal positional vertigo (BPPV). A ≥40-year-old Korean population was included. A total of 34,441 patients with BPPV was matched with 137,764 comparison participants for demographic and socioeconomic factors. Previous histories of PPI use and PPI prescription dates were compared between the BPPV and comparison groups. The odds ratios (ORs) with 95% confidence intervals (CIs) of PPI use for BPPV were calculated using a logistic regression. The demographic and socioeconomic factors and comorbidities were adjusted in the adjusted model. Both current and past PPI users were associated with higher odds for BPPV than non-PPI users (adjusted OR (aOR) = 3.57, 95% CI = 3.33−3.83, and p < 0.001 for current PPI users and aOR = 1.76, 95% CI = 1.64−1.89, and p < 0.001 for past PPI users). In addition, longer dates of PPI use were related to higher odds for BPPV (aOR (95% CI) = 1.95 [1.81−2.10] for ≥1 day and <30 days of PPI prescription, <2.88 [2.68−3.10] for ≥30 days and <365 days of PPI prescription, and <3.45 [3.19−3.73] for ≥365 days of PPI prescription). PPI use was linked with an elevated risk of BPPV in the adult population. The odds for BPPV were higher in patients with a longer duration of PPI use.

Vestibular migraine

Vestibular migraine (VM) remains an underdiagnosed condition, often mistaken with brainstem aura. VM is defined by recurrent vestibular symptoms in at least 50% of migraine attacks. Diagnosis is established by clinical criteria based on the International Classification of Headache Disorders (ICHD-3). Estimated prevalence of VM is 1 to 2.7% of the adult population. Vestibular symptoms usually appear after the headache. VM pathophysiology remains poorly understood. Vertigo may occur before, during, after the migraine attack, or even independently, and may last seconds to hours or days. Pathophysiological mechanisms for VM are still poorly understood and are usually extrapolated from migraines. Differential diagnoses include Ménière's disease, benign paroxysmal positional vertigo, brainstem aura, transient ischemic attack, persistent perceptual postural vertigo, and episodic type 2 ataxia. Specific treatment recommendations for vestibular migraine are still scarce.

Vestibular Test Results in Patients With Horizontal Canal Benign Paroxysmal Positional Vertigo

Introduction

While the mechanism of posterior canal benign paroxysmal positional vertigo (BPPV) is widely accepted as canalolithiasis, the pathophysiology of horizontal canal BPPV remains controversial. We seek to analyze vestibular test results of patients with horizontal canal BPPV with ageotropic nystagmus (AHC) and geotropic nystagmus (GHC) in comparison to patients with posterior canal BPPV (PC) to better understand its pathophysiology.

Methods

In a retrospective chart review of adults with BPPV at a tertiary referral balance center, we reviewed the clinical characteristics and compared videonystagmography, caloric, rotary chair, subjective visual vertical (SVV)/ subjective visual horizontal (SVH), and vestibular evoked myogenic potential (VEMP) results between groups.

Results

We included 11 AHC and seven GHC patients and randomly selected 20 PC patients as the comparison group. All groups had a high rate of migraine and low rates of diabetes and head trauma, but no difference between groups. Ipsilateral caloric weakness was more prevalent in the GHC group compared to the PC group (p=0.02). One of two AHC patients and both GHC patients who had SVV/SVH testing had abnormal findings. The only AHC patient who had ocular VEMP testing had abnormal results. Additionally, we observed a significant downbeating component to nystagmus (4 deg/sec or greater) exclusively in the AHC group (5/10 patients, p=0.001).

Conclusions

Patients with AHC and GHC have unique vestibular testing results. In particular, only AHC patients showed a downbeating component to their nystagmus, which may suggest utricular dysfunction in the pathophysiology of AHC.

Persistent postural perceptual dizziness following paroxysmal positional vertigo in migraine

Objective

This prospective study aimed to investigate the role of migraine in favouring the onset of persistent postural perceptual dizziness (PPPD) following paroxysmal positional vertigo (PPV).

Methods

A group of patients who came to our attention suffering of PPV with or without migraine and/or vestibular migraine (VM) was examined. Three months after the resolution, an anamnestic research was conducted aimed at establishing whether any patient-related dizziness could meet the diagnostic criteria for PPPD.

Results

12 of the 240 patients recruited met the diagnostic criteria for PPPD for an overall incidence of 5%, with 3 (1.85%) belonging to the non-migraine group and 9 (11.5%) to the migraine group. In the latter, 6 (28.6%) patients with VM and 3 (5.26%) without VM were affected.

Conclusions

The study shows a significant increase of PPPD diagnosis in migraine compared to patients without migraine (p = 0.003). Within migraine there was a significant increase in those with VM compared to patients without VM (p = 0.0016). No difference emerged between patients without migraine and migraine patients without VM (p > 0.05). The presence of VM in patient’s history, but not migraine without VM, appears to significantly increase the incidence of PPPD in patients with PPV.

Comorbidities of primary headache disorders: a literature review with meta-analysis

Background

Primary headache disorders are common and burdensome conditions. They are associated to several comorbidities, such as cardiovascular or psychiatric ones, which, in turn, contribute to the global burden of headache. The aim of this study is to provide a comprehensive description of the pooled prevalence of comorbidities of primary headache disorders using a meta-analytical approach based on studies published between 2000 and 2020.

Methods

Scopus was searched for primary research (clinical and population studies) in which medical comorbidities were described in adults with primary headache disorders. Comorbidities were extracted using a taxonomy derived from the Global Burden of Disease (GBD) study. We compared prevalence of comorbidities among headache sufferers against general population using GBD-2019 estimates, and compared comorbidities’ proportions in clinical vs. population studies, and by age and gender.

Results

A total of 139 studies reporting information on 4.19 million subjects with primary headaches were included: in total 2.75 million comorbidities were reported (median per subject 0.64, interquartile range 0.32–1.07). The most frequently addressed comorbidities were: depressive disorders, addressed in 51 studies (pooled proportion 23 %, 95 % CI 20–26 %); hypertension, addressed in 48 studies (pooled proportion 24 %, 95 % CI 22–26 %); anxiety disorders addressed in 40 studies (pooled proportion 25 %, 95 % CI 22–28 %). For conditions such as anxiety, depression and back pain, prevalence among headache sufferers was higher than in GBD-2109 estimates. Associations with average age and female prevalence within studies showed that hypertension was more frequent in studies with higher age and less females, whereas fibromyalgia, restless leg syndrome, and depressive disorders were more frequent in studies with younger age and more female.

Conclusions

Some of the most relevant comorbidities of primary headache disorders – back pain, anxiety and depression, diabetes, ischemic heart disease and stroke – are among the most burdensome conditions, together with headache themselves, according to the GBD study. A joint treatment of headaches and of these comorbidities may positively impact on headache sufferers’ health status and contribute to reduce the impact of a group of highly burdensome diseases.

Supplementary Information

The online version contains supplementary material available at 10.1186/s10194-021-01281-z.

Bidirectional association between migraine and rheumatoid arthritis: two longitudinal follow-up studies with a national sample cohort

OBJECTIVE

To investigate the bidirectional association between migraine and rheumatoid arthritis (RA).

DESIGN

Two longitudinal follow-up studies.

SETTING

Data collected from a national cohort between 2002 and 2013 by the Korean National Health Insurance Service-Health Screening Cohort.

PARTICIPANTS

In cohort 1, matching resulted in the inclusion of 31 589 migraine patients and 126 356 control I participants. In cohort 2, matching resulted in the inclusion of 9287 RA patients and 37 148 control II participants.

PRIMARY AND SECONDARY OUTCOME MEASURES

The HRs for RA in patients with migraine (cohort 1) and migraine in patients with RA (cohort 2) were analysed using stratified Cox proportional hazard models after adjusting for autoimmune disease, Charlson Comorbidity Index scores without rheumatoid diseases, obesity (body mass index), smoking and history of alcohol intake. Subgroup analyses stratified by age, sex, income and region of residence were also performed.

RESULTS

The incidence of RA in the migraine group (2.0% (640/31 589)) was higher than that in the control I group (1.4% (1709/126 356), p<0.001). The adjusted HR for RA in the migraine without aura group was 1.48 (95% CIs=1.34 to 1.63, p<0.001).The incidence of migraine in the RA group (6.4% (590/9287)) was higher than that in the control II group (4.6% (1721/37 148), p<0.001). The adjusted HR for migraine without aura in the RA group was 1.35 (95% CI=1.23 to 1.49, p<0.001).

CONCLUSION

Migraine increases the risk of RA, and RA is also associated with an increased risk of migraine.

Effect of right-to-left shunt on youth benign paroxysmal positional vertigo: A prospective clinical study

OBJECTIVE

To evaluate the correlation between right to left shunt (RLS) and youth benign paroxysmal positional vertigo (YBPPV).

PATIENTS AND METHODS

Patients with benign paroxysmal positional vertigo (BPPV) and normal control cases younger than 45 years were enrolled at 1:1 ratio. Contrast-enhanced transcranial doppler ultrasound was performed to determine the existence and shunt grading of RLS. Regression analysis was conducted by including other possible risk factors for YBPPV to evaluate whether RLS acts as an independent risk factor.

RESULTS

A total of 174 cases were enrolled, with 87 cases in the YBPPV group and 87 cases in the normal control group. The proportion of existing RLS in the YBPPV group was significantly higher than in the normal control group (65.52% vs. 28.74%, P < 0.001). Regression analysis showed that RLS was an independent risk factor for YBPPV (odds ratio = 2.157, 95% credibility interval: 1.504～3.093, P＜0.001). In the YBPPV group, the recurrence of BPPV within 180 days showed no statistical difference between cases with RLS and receiving anti-platelet treatment and cases with RLS and without anti-platelet treatment. In the YBPPV group, the recurrence of BPPV within 180 days in cases without RLS and anti-platelet treatment did not significantly differ from cases with RLS and without anti-platelet treatment and cases with RLS and receiving anti-platelet treatment.

CONCLUSION

In the present study, RLS resulted as an independent risk factor for YBPPV. This observation could generate hypotheses of the mechanism by which a RLS could induce YBPPV.

Psoriasis Increases the Risk of Sudden Sensorineural Hearing Loss: A Longitudinal Follow Up Study Using a National Sample Cohort

Psoriasis is a well-known immune-mediated disease. Its autoimmune pathophysiology is consistent with the immune-mediated systemic vascular hypothesis regarding the pathogenesis of sudden sensorineural hearing loss (SSNHL). The purpose of our study was to investigate whether psoriasis affects the prevalence of SSNHL in all age groups matched by age, sex, income, and region of residence. Korean Health Insurance Review and Assessment Service-National Patient Samples were collected from 2002 to 2013. A 1:4 matched psoriasis group (n = 12,864) and control group (n = 51,456) were selected. The crude (simple) and adjusted (Charlson comorbidity index) hazard ratios (HR) for psoriasis and SSNHL were analyzed using the stratified Cox proportional hazard model. The incidence of SSNHL was significantly higher in the psoriasis group than in the control group (0.5% vs. 0.4%, p = 0.004). Psoriasis increased the risk of SSNHL (adjusted HR = 1.44, 95% confidence interval (CI) = 1.09–1.90, p = 0.010). In the stratification analysis, the incidence of SSNHL was significantly higher in the 30–59-year-old group than other group SSNHL (adjusted HR = 1.50, 95% CI = 1.06–2.12, p = 0.023). In addition, SSNHL occurred significantly more frequently in men with psoriasis (adjusted HR = 1.70, 95% CI = 1.17–2.49, p = 0.006). Psoriasis increased the risk of SSNHL, and SSNHL was more prevalent in between the age of 30–59-year-olds and men with psoriasis.

Video head impulse testing in patients with benign paroxysmal positional vertigo

BACKGROUND

Vestibulo-ocular reflex (VOR) function is expected to be normal in patients with benign paroxysmal positional vertigo (BPPV) during sudden head rotations.

AIM

The aim of this study is to analyze VOR by video head impulse test (vHIT) in patients with BPPV in order to determine the potential value of clinical application of vHIT in BPPV.

MATERIAL AND METHOD

Sixty patients with BPPV were included for the study from out-patient admissions. The main outcome measures were the gain of VOR, gain asymmetry, and refixation saccades. Fifteen healthy subjects with no history of dizziness were selected as normal control.

RESULTS

Mean VOR gain during lateral head impulse in patients with geotropic type LC BPPV was 0.85 ± 0.22. Mean VOR gain during lateral head impulse in patients with ageotropic type LC BPPV was 0.78 ± 0.16. Fourteen patients with PC BPPV (35%; 40/13) had low gain during ipsilesional head impulses. Seven patients had low gain during counterlesional head impulses. Mean VOR gain during vertical head impulse in patients with PC BPPV was 0.73 ± 0.24. Nine patients with posterior canal BPPV (25%; 9/40) and 2 patients with LC BPPV (11%; 2/18) had corrective saccades. None of the results showed significant difference in comparison to control group.

CONCLUSION AND SIGNIFICANCE

VHIT analysis demonstrated that VOR function was normal on the BPPV side.

Comparison of associated comorbid conditions in patients with benign paroxysmal positional vertigo with or without migraine history: A large single institution study

PURPOSE

In the largest reported United States (U.S.) cohort of benign paroxysmal positional vertigo (BPPV), does the presence or absence of migraine correlate with increased associations of other factors?

MATERIALS & METHODS

A retrospective chart review from a single U.S. neurotology center. Adult patients with BPPV from 2003 to 2017 classified into two groups: 1) with migraine; 2) without migraine.

RESULTS

The prevalence of self-reported migraine history in a BPPV-positive population (n = 1481) was 25.8% (n = 382). Among those with BPPV and migraine, 88.5% were female, 8.1% had diabetes, 22.5% had prior history of BPPV, 8.9% had Meniere's disease and recurrence rate was 38.3%. No statistically significant differences between recurrence or resolution rates between the two groups were demonstrated (p > 0.05). Adjusted logistic regression model found that women and those with a prior history of BPPV had significantly higher odds of having both BPPV and migraine conditions compared to their counterparts. In contrast, older age and diabetes were associated with significantly lower odds of concomitant BPPV and migraine.

CONCLUSIONS

The prevalence of migraine among the study sample was 25.8%. Female gender, prior history of BPPV, younger age, and lack of diabetes were independently associated with the concurrent comorbidity of BPPV and migraine. These data further substantiate previously reported rates (from smaller studies); and, demonstrate that recurrence and resolution rates are not worse in those with BPPV and migraine compared to the general BPPV population. Findings support an association between migraine and BPPV and enhances one's ability to accurately counsel patients regarding these diseases.

Association between benign paroxysmal positional vertigo and osteoporosis: two nested case-control studies

Benign paroxysmal positional vertigo (BPPV) was related to a 1.28 times higher risk of osteoporosis. In addition, osteoporosis was associated with a 1.34 times higher risk of BPPV. This bidirectional relation was maintained after adjusting past medical histories and lifestyle factors, including obesity, smoking, and alcohol consumption. To our knowledge, this is the first study to explore the reciprocal association between BPPV and osteoporosis. In subgroup analyses, only women showed a reciprocal association between BPPV and osteoporosis.

INTRODUCTION

A previous population cohort study suggested an association between osteoporosis and benign paroxysmal positional vertigo (BPPV). This study aimed to investigate the bidirectional association between BPPV and osteoporosis.

METHODS

The Korean National Health Insurance Service-Health Screening Cohort data from 2002 to 2013 were used. In study I, the 50,897 osteoporosis patients were 1:1 matched with control I participants for age, sex, income, and region of residence. The previous histories of BPPV were analyzed in both groups using conditional logistic regression analysis. In study II, 9621 BPPV patients were 1:4 matched with control II participants. The previous histories of osteoporosis were analyzed in both groups using conditional logistic regression analysis. According to age and sex, subgroup analyses were achieved in both studies I and II.

RESULTS

A total of 1.6% (822/50,897) of osteoporosis patients and 1.3% (644/50,897) of control I participants had BPPV. The osteoporosis patients demonstrated a 1.28 times higher chance of developing BPPV (95% confidence intervals [95% CI] = 1.16-1.42, P < 0.001). In study II, 21.2% (2040/9621) of BPPV patients and 17.6% (6790/38,484) of control II participants had osteoporosis. The BPPV patients showed 1.34 times higher chance of having osteoporosis (95% CI = 1.26-1.43, P < 0.001). In the analysis of the women subgroup, these relations were reliable.

CONCLUSION

Osteoporosis patients had increased odds of having BPPV. On the other hand, BPPV patients had increased odds of having osteoporosis. This bidirectional relation was consistent only in the women subgroup.

Management of Lateral Semicircular Canal Benign Paroxysmal Positional Vertigo

Benign paroxysmal positional vertigo (BPPV) is the most common cause of peripheral vestibular vertigo. It is caused by free-floating otoconia moving freely in one of the semicircular canals (canalolithiasis) or by otoliths adhered to the cupula (cupulolithiasis). The posterior canal is the most common canal affected, followed by the lateral canal. Diagnosis of the side affected is critical for successful treatment; therefore, suppressing visual fixation is essential to examination of these patients' eye movement. On the basis of our experience, we have adopted the Zuma maneuver and the modified Zuma maneuver for both apogeotropic and geotropic variants of lateral canal BPPV. Knowledge of the anatomy and pathophysiologic mechanisms of the semicircular canals is essential for correct management of these patients. Hence, using a single maneuver and its modification may facilitate daily neurotological practice.

Risk Factors for the Occurrence of Benign Paroxysmal Positional Vertigo: A Systematic Review and Meta-Analysis

Background and Purpose: The lifetime prevalence of benign paroxysmal positional vertigo (BPPV) is high, especially in the elderly. Patients with BPPV are more susceptible to ischemic stroke, dementia, and fractures, severely reducing quality of life of patients. Many studies have analyzed risk factors for the occurrence of BPPV. However, the results of these studies are not identical. We performed this meta-analysis to determine potential risk factors associated with the occurrence of BPPV.

Methods: PubMed, EMBASE, and the Cochrane Library (January 2000 through March 2020) were systematically searched for eligible studies analyzing risk factors for the occurrence of BPPV. Reference lists of eligible studies were also reviewed. We selected observational studies in English with a control group and sufficient data. Pooled odds ratios (ORs) or the mean differences (MDs) and 95% confidence intervals (CIs) were calculated to measure the impacts of all potential risk factors. Heterogeneity among studies was evaluated using the Q-test and I² statistics. We used the random-effect model or the fixed-effect model according to the heterogeneity among the included studies.

Results: We eventually included 19 studies published between 2006 and 2019, including 2,618 patients with BPPV and 11,668 participants without BPPV in total. In this meta-analysis, the occurrence of BPPV was significantly associated with female gender (OR = 1.18; 95% CI, 1.05–1.32; P = 0.004), serum vitamin D level (MD = −2.12; 95% CI, −3.85 to −0.38; P = 0.02), osteoporosis (OR = 2.49; 95% CI, 1.39–4.46; P = 0.002), migraine (OR = 4.40; 95% CI, 2.67–7.25; P < 0.00001), head trauma (OR = 3.42; 95% CI, 1.21–9.70; P = 0.02), and total cholesterol level (MD = 0.32; 95% CI, 0.02–0.62; P = 0.03).

Conclusion: Female gender, vitamin D deficiency, osteoporosis, migraine, head trauma, and high TC level were risk factors for the occurrence of BPPV. However, the effects of other risk factors on BPPV occurrence need further investigations.

Vestibular Disorders

BACKGROUND

Recent research findings have improved the understanding of the diagnosis, pathophysiology, genetics, etiology, and treatment of peripheral, central, and functional vestibular vertigo syndromes.

METHOD

A literature search, with special attention to the current classification, treatment trials, Cochrane analyses, and other meta-analyses.

RESULTS

There are internationally accepted diagnostic criteria for benign positional paroxysmal vertigo, Menière's disease, bilateral vestibulopathy, vestibular paroxysmia, and functional dizziness. Whether an acute vestibular syndrome is central or peripheral can usually be determined rapidly on the basis of the history and the clinical examination. "Cere - bellar vertigo" is a clinically important entity. For bilateral vestibulopathy, balance training is an effective treatment. For Menière's disease, preventive treatment with betahistine (48 mg and 144 mg per day) is not superior to placebo. For vestibular paroxysmia, oxcarbazepine has been shown to be effective. Treatments that are probably effective for functional dizziness include vestibular rehabilitation, cognitive behavioral therapy, and serotonin reuptake inhibitors.

CONCLUSION

The diagnostic assessment of vestibular syndromes is much easier for clinicians now that it has been internationally standardized. There is still a lack of randomized, controlled trials on the treatment of, for example, Menière's disease, vestibular migraine, and "cerebellar vertigo."

Review of the pathology underlying benign paroxysmal positional vertigo

The pathophysiological mechanism underlying benign paroxysmal positional vertigo (BPPV) is related to free-floating debris/otoliths in the semicircular canal (canalolithiasis) or debris/otoliths attached to the cupula (cupulolithiasis). These debris/otoliths are considered to originally accumulate after detachment from the neuroepithelium of the utricular macula secondary to a type of degeneration. An idiopathic form, which is assumed to occur spontaneously, is diagnosed when the causative pathology is obscure. However, an association between various other systemic or inner ear conditions and BPPV has been reported, indicating the existence of secondary BPPV. This study was performed to present the first review of the pathology underlying BPPV following a complete PubMed/Medline search. In total, 1932 articles published from 1975 to 2018 were reviewed. The articles were classified according to 17 potentially causative factors (aging; migraine; Meniere's disease; infection; trauma; idiopathic sudden sensorineural hearing loss; sleeping habits; osteoporosis and vitamin D insufficiency; hyperglycemia and diabetes mellitus; chronic head and neck pain; vestibule or semicircular canal pathology; pigmentation disorders; estrogen deficiency; neurological disorders; autoimmune, inflammatory, or rheumatologic disorders; familial or genetic predisposition; and allergy). A discussion of the underlying cause of BPPV for each factor is presented.

Benign Positional Paroxysmal Vertigo Treatment: a Practical Update

PURPOSE OF THE REVIEW

To define the best up-to-date practical approach to treat benign paroxysmal positional vertigo (BPPV).

RECENT FINDINGS

Both posterior and horizontal canal BPPV canalith repositioning maneuvers (Semont, Epley, and Gufoni's maneuvers) are level 1 evidence treatment for evidence-based medicine. The choice of maneuver (since their efficacy is comparable) is up to the clinician's preferences, failure of the previous maneuver, or movement restrictions of the patient. Maneuvers for controversial variants, such as anterior canal and apogeotropic posterior canal BPPV, have weaker evidence of efficacy. Despite this, these variants are increasingly diagnosed and treated. Maneuvers also play a role in the differential diagnosis with central vestibular disorders. Chair-assisted treatment may be of help if available while surgical canal plugging should be indicated in selected same-canal, same-side intractable severe BPPV. The primary evidence-based treatment strategy for BPPV should be physical therapy through maneuvers. Despite the high success rate of liberatory maneuvers, there is a low percentage of subjects who have unsatisfactory outcomes. These patients need to be investigated to identify recurrences, multiple canal involvement, associated comorbidities (migraine, persistent postural perceptual dizziness), or risk factors for recurrences (low vitamin D serum level). Future research should also identify the optimum maneuvers for variants whose diagnosis and treatment are still a matter of some debate.