The effects of betahistine in addition to epley maneuver in posterior canal benign paroxysmal positional vertigo

Residual dizziness after BPPV management: exploring pathophysiology and treatment beyond canalith repositioning maneuvers

Despite the high success rate of canalith repositioning maneuvers (CRMs) in the treatment of benign paroxysmal positional vertigo (BPPV), a growing number of patients report residual dizziness symptoms that may last for a significant time. Although the majority of BPPV cases can be explained by canalolithiasis, the etiology is complex. Consideration of the individual patient's history and underlying pathophysiology of BPPV may offer the potential for treatment approaches supplementary to CRMs, as well as a promising alternative for patients in whom CRMs are contraindicated. This article provides a summary of the possible underlying causes of BPPV and residual dizziness, along with suggestions for potential management options that may be considered to relieve the burden of residual symptoms.

Clinical Efficacy and Metabolomics Modifications Induced by Polyphenol Compound Supplementation in the Treatment of Residual Dizziness following Semont Maneuver in Benign Paroxysmal Positional Vertigo (BPPV) of the Posterior Semicircular Canal (PSC): Preliminary Results

Benign paroxysmal positional vertigo (BPPV) represents the most frequent cause of peripheral vertigo. In most cases, it is successfully treated using the canalith repositioning procedure, but it is often followed by continuous lightheadedness in the absence of vertigo or nystagmus (residual dizziness, RD). Our aim is to describe the clinical effectiveness and the urine metabolomics profile of treating these patients with polyphenol compound supplementation. We enrolled 30 patients reporting RD after BPPV of the posterior semicircular canal (PSC) successfully treated using the Semont maneuver. Supplementation with a polyphenol compound was administered for 60 days, and patients were evaluated after 30 and 60 days of treatment using self-administered questionnaires (Visual Analog Scales for Dizziness and Nausea, Dizziness Handicap Inventory, DHI) and urine metabolomics analysis performed using 1H-NMR spectroscopy and multivariate followed by univariate analysis. Most patients reported excellent or good efficacy in the treatment of RD with a significant decrease in VAS and DHI values. The metabolomics analysis identified six significant metabolites related to the treatment, namely 1-methylnicotinamide, anserine, hippurate, lysine, methyl succinate and urea, indicating the inflammatory activities and antioxidant properties of the polyphenol compound. These preliminary data suggest that supplementation with a polyphenol compound could induce some metabolic changes that can help in recovery from RD. However, future steps will require confirmation with a more significant cohort of patients and an extension of the metabolomics evaluation to other problems concerning the different clinical aspects of BPPV, such as the high rate of relapse.

Comparative Effectiveness Research: Betahistine add-on Therapy with Epley's Manoeuvre Versus Epley's Manoeuvre Alone in Treating Posterior BPPV Patients

INTRODUCTION

Benign paroxysmal positional vertigo is one of the common vestibular disorders encountered in ENT clinics with accompanying vertigo. Study to evaluate the additive effects of betahistine on Epley's manoeuvre in treating posterior BPPV patients.

MATERIAL AND METHODS

Prospective study was conducted on 50 patients of posterior BPPV diagnosed by the Dix Hallpike test. Subjects were divided into Group A which received the Betahistine therapy along with the canalith repositioning technique (Epley's manoeuvre) and the second group (Group B) which received the Epley's manoeuvre alone. The patients were assessed at 1 week and 4 weeks by Visual Analogue Scale (VAS), Dizziness Handicap Inventory (DHI) and Short Form 36 (SF-36).

RESULTS

At the end of 4 weeks, 2 patients in group A (E + B) had positive Dix-Hallpike and 23(92%) had negative Dix-Hallpike, while 11 patients in group B (E) had positive Dix-Hallpike and 14 (56%) had negative Dix-Hallpike with P value < 0.001. The Mean baseline (T0) Visual Analogue Scale (VAS) score in group A (E + B) was 8.60 ± 1.080 and in group B (E) was 8.92 ± 0.996. Post-treatment VAS score was significantly lower in both the groups and was significantly lower in group A(E + B) than in group B (E) (0.680 ± 1.930 vs. 3.96 ± 3.587, respectively, p-value < 0.001). The Mean baseline (T0) Dizziness Handicap Inventory (DHI) scores were similar in groups A and B (77.36 ± 9.49 vs. 80.00 ± 8.9, respectively, p = 0.271). After treatment, the DHI values were significantly lower in both groups. Group A had a better DHI score than group B (10.56 ± 17.12 vs. 44.72 ± 27.35, p < 0.001). The mean baseline (T0) Short Form 36 (SF-36) scores were also similar in groups A and B (19.53 ± 6.85 vs. 18.79 ± 5.50, p = 0.823). Post-treatment of 4 weeks, the SF-36 score significantly improved in both the groups and significantly improved in group A than group B (84.27 ± 17.28 vs. 46.53 ± 24.53, p < 0.001).

CONCLUSION

Betahistine therapy in conjunction with Epley's manoeuvre leads to better symptom control and is more effective than Epley's alone in treating BPPV patients.

Efficacy of Epley's maneuver plus betahistine in the management of PC-BPPV: A systematic review and meta-analysis

BACKGROUND

To evaluate the efficacy of Epley's maneuver plus betahistine in the management of patients with posterior canal benign paroxysmal positional vertigo (PC-BPPV).

METHODS

Electronic databases including PubMed, Embase, Web of Science, Cochrane Library, Chinese National Knowledge Infrastructure, and Wanfang were searched from their inception to April, 2022. The effect size was analyzed by calculating the pooled risk ratio estimates of efficacy rate, recurrence rate, and standardized mean differences (SMD) of dizziness handicap inventory (DHI) score with a 95% confidence interval (CI). Sensitive analysis was performed simultaneously.

RESULTS

A total of 9 randomized controlled trials with 860 PC-BPPV patients were included in the meta-analysis, in which 432 were treated with Epley's maneuver plus betahistine, and 428 received Epley's maneuver alone. The meta-analysis revealed that Epley's maneuver plus betahistine significantly improved DHI score than Epley's maneuver alone (SMD = -0.61, 95% CI -0.96 to -0.26, P = .001). In addition, both Epley's maneuver plus betahistine and Epley's maneuver groups had comparable outcomes in efficacy rate and recurrence rate.

CONCLUSION

This meta-analysis shows that Epley's maneuver plus betahistine in PC-BPPV patients had favorable effects on DHI score.

Comparison of the efficacy of the Epley maneuver and repeated Dix-Hallpike tests for eliminating positional nystagmus: A multicenter randomized study

Background and objectives

Patients with benign paroxysmal positional vertigo of the posterior canal (pc-BPPV) exhibit BPPV fatigue, where the positional nystagmus diminishes with the repeated performance of the Dix-Hallpike test (DHt). BPPV fatigue is thought to be caused by the disintegration of lumps of otoconial debris into smaller parts and can eliminate positional nystagmus within a few minutes [similar to the immediate effect of the Epley maneuver (EM)]. In this study, we aimed to show the non-inferiority of the repeated DHt to the EM for eliminating positional nystagmus after 1 week.

Methods

This multicenter, randomized controlled clinical trial was designed based on the CONSORT 2010 guidelines. Patients who had pc-BPPV were recruited and randomly allocated to Group A or Group B. Patients in Group A were treated using the EM, and patients in Group B were treated using repeated DHt. For both groups, head movements were repeated until the positional nystagmus had been eliminated (a maximum of three repetitions). After 1 week, the patients were examined to determine whether the positional nystagmus was still present. The groups were compared in terms of the percentage of patients whose positional nystagmus had been eliminated, with the non-inferiority margin set at 15%.

Results

Data for a total of 180 patients were analyzed (90 patients per group). Positional nystagmus had been eliminated in 50.0% of the patients in Group A compared with 47.8% in Group B. The upper limit of the 95% confidence interval for the difference was 14.5%, which was lower than the non-inferiority margin.

Discussion

This study showed the non-inferiority of repeated DHt to the EM for eliminating positional nystagmus after 1 week in patients with pc-BPPV and that even the disintegration of otoconial debris alone has a therapeutic effect for pc-BPPV. Disintegrated otoconial debris disappears from the posterior canal because it can be dissolved in the endolymph or returned to the vestibule via activities of daily living.

Classification of evidence

This study provides Class II evidence of the non-inferiority of repeated DHt to the EM for eliminating positional nystagmus after 1 week.

Registration number

UMIN000016421.

Effects of Betahistine on Vestibulo-Ocular Reflex in Normal Healthy Adults: A Randomized Double-Blind, Placebo-Controlled Trial

Introduction

Vertigo, or the perception of a spinning sensation, is a common symptom experienced by patients who are referred to Otorhinolaryngology clinics. Betahistine is a medication that has been widely used to treat vertigo and its accompanying symptoms. However, the effects of this medication on the vestibulo-ocular reflex (VOR) are still unknown. Initially, it was assumed that betahistine should be discontinued prior to any vestibular tests, particularly the video head impulse test (vHIT).

Method

Thirty young healthy adults were randomly divided into two equal groups for this randomized double-blind clinical study (betahistine 24 mg and placebo). Baseline pure-tone audiometry (PTA), tympanometry, and VOR measurements were taken, followed by experimental measurements at one hour, four hours, eight hours, and 24 hours after consumption. The video head impulse test (vHIT) was used to determine the VOR.

Result

Betahistine had no statistically significant effect on vestibulo-ocular reflex gain (F(4,140) = 0.601, p = 0.662). The gain variability across repetitive head impulses remained constant over time.

Conclusions

Betahistine has no effect on the vestibulo-ocular reflex. As a result, this medication can be taken prior to the vHIT procedure.

Effectiveness of the Epley maneuver versus Cawthorne-Cooksey vestibular exercises in the treatment of posterior semicircular canal benign paroxysmal positional vertigo (BPPV): A randomized controlled trial

OBJECTIVE

Benign paroxysmal positional vertigo (BPPV) is the most common cause of peripheral vertigo that mainly affects the posterior semicircular canal. Studies suggest that Epley maneuver could improve balance of patients, but Cawthorne-Cooksey vestibular exercises are still scarce. This study aimed to observe the effects of Cawthorne-Cooksey vestibular exercises applied after the Epley maneuver on balance, vertigo symptoms, and quality of life in posterior semicircular canal BPPV.

METHODS

Thirty-six patients with posterior semicircular canal BPPV were randomly assigned into Epley maneuver (EpleyM) and Epley maneuver and exercise (EpleyM&Exe) groups. All patients were treated with the Epley maneuver, while Cawthorne-Cooksey vestibular exercises were given to the EpleyM&Exe group as home exercises for 6 weeks. Their static and dynamic balance, vertigo symptoms, and quality of life were assessed at pre-, post-intervention (1st, 3rd and 6th weeks).

RESULTS

Thirty-two patients completed the study (mean age: 46.91 ± 9.78 years). Epley maneuver applied alone and combined with Cawthorne-Cooksey vestibular exercises, was found to be effective in 25 patients (78.1%), 6 patients (18.8%) and 1 patient (3.1%) at the 1st, 3rd and 6th weeks, respectively. After 6 weeks, both groups had gained significant improvements in balance, vertigo symptoms, and quality of life (p < 0.001); however, there were no significant differences between the groups, except for the static dominant leg balance test (p = 0.022).

CONCLUSIONS

The Epley maneuver can be considered as the first option compared to Cawthorne-Cooksey vestibular exercises. Exercises do not appear to have any additional effects in improving posterior semicircular canal BPPV symptoms.

Current Insights into Treating Vertigo in Older Adults

The number of older people has been increasing over recent decades in Western populations. Dizziness, imbalance, and vertigo constitute some of the most common complaints in older patients, and risk of falling is the most frequent and worrying consequence. It has been reported that 15–20% of the adult population experiences these debilitating symptoms. Among the diseases that may be associated with vertigo, the three classes of otological, central, and functional (psychological) dizziness may be distinguished. Overall, vestibular disorders account for 48% of vertiginous complaints in the older population. The main focus of this article is to review the forms of pharmacotherapy for vertigo, especially with regard to older patients, who may be treated simultaneously with other drugs for different comorbidities. Interactions with other drugs should be considered in the choice of a particular course of treatment. Moreover, overuse of pharmacotherapy for the management of vertigo in the elderly may prevent the development of the central compensatory mechanism that sustains both static and dynamic imbalance after a vertiginous crisis. In the majority of patients, vestibular and physical rehabilitation are strongly advised and rarely contraindicated.

Characteristics of Benign Paroxysmal Positional Vertigo Following an Earthquake

INTRODUCTION

Benign Paroxysmal Positional Vertigo (BPPV) is a commonly encountered peripheral vestibular disorder. People exposed to massive earthquakes experience intense and long-term problem associated with dizziness. The purpose of our study is to investigate this relationship and to demonstrate the efficacy of the treatment modalities used in the management of patients with post-earthquake dizziness.

METHODOLOGY

The study was carried out by examining the retrospective records of patients who presented with dizziness to the otorhinolaryngological outpatient unit before and after the Elazig earthquake that occurred on 24th Jan 2020. Parameters evaluated include patients' age and gender, onset of dizziness, accompanying symptoms and comorbidities, videonystagmography (VNG) findings, pre- and post-treatment Visual Analogue Scale (VAS), Dizziness Handicap Inventory (DHI), and Hospital Anxiety and Depression Scale (HADS).

RESULTS

The number of patients who presented with dizziness to our outpatient clinic after the earthquake and were included in our study totaled 84. The number of patients who visited the outpatient clinic before the earthquake was identified to be 75. In the earthquake related group, while there was a statistically significant difference between residual symptoms (RS) and the need for repetitive repositioning maneuvers, there was no statistically significant difference detected for age, gender, and comorbidities. Also, no statistically significant difference was found in the pre- and post-treatment assessments of VAS, DHI, and HADS median values in the earthquake group.

CONCLUSION

There was a remarkable increase in the number of patients presenting with dizziness in the early post-earthquake period. Management of these patients may differ from the classic BPPV. Residual symptoms appearing after performing repositioning maneuvers can be more commonly seen among these patients.

Comparison of Activity-Based Home Program and Cawthorne-Cooksey Exercises in Patients With Chronic Unilateral Peripheral Vestibular Disorders

OBJECTIVE

This study aimed to investigate the effects of an activity-based home program and an exercise-based home program on dizziness severity, balance, and independent level of daily life activities in patients with dizziness due to chronic unilateral peripheral vestibular disorders.

DESIGN

A single-blind randomized controlled trial.

SETTING

University dizziness management clinics.

PARTICIPANTS

Individuals (N=75) between 18 and 65 years of age who had chronic unilateral peripheric vestibular disorders and vestibular rehabilitation indication.

INTERVENTION

Participants were randomly divided into 3 groups: an activity-based home program (group 1/activity group), an exercise-based home program (group 2/exercise group), and a control group (group 3). After an initial assessment, all groups participated in the patient education program. In addition, the activity-based home program was administered to the first group, while the Cawthorne-Cooksey home exercise program was administered to the second group.

MAIN OUTCOME MEASURES

Visual analog scale (VAS), Vestibular Disorders Activities of Daily Living Scale (VADL), and computerized dynamic posturography before and immediately after the treatment program.

RESULTS

A statistically significant improvement was found in the activity and exercise groups in terms of VAS, VADL, Sensory Organization Test (SOT) 5, SOT 6, and SOT (composite) scores compared with the control group (P<.05). A statistically significant improvement was found in the activity group in terms of the instrumental subscale of VADL, SOT 5, SOT 6, and SOT (composite) scores compared with the exercise group.

CONCLUSIONS

The activity-based home program was more effective in improving the home management task, the occupational task, and balance than the exercise-based home treatment program in patients with chronic peripheral vestibular disorders.

Benign paroxysmal positional vertigo in emergency department: How to treat?

Background:

The treatment of benign paroxysmal positional vertigo (BPPV) has not been well studied. Many clinicians are indifferent about canalith reposition maneuvers and frequently prefer medical treatments.

Objectives:

We aimed to detect efficacy of Epley maneuver in relieving symptoms of benign paroxysmal positional vertigo patients diagnosed in emergency department and if medical treatments are useful in patients whose symptoms were not relieved.

Methods:

The study was conducted as a prospective cohort study in the emergency department of a tertiary hospital. Patients who were over 18 years of age and presented to emergency department with complaints of vertigo symptoms and nausea and had a positive Dix–Hallpike test were included in the study. Patients’ demographic data, possible etiological factors, affected ear, and benign paroxysmal positional vertigo diagnosis in the history were recorded on the study data form. The European Evaluation of Vertigo scale and the Visual Analogue Scale (VAS) score of nausea and vertigo symptoms were graded and recorded for each patient before and after treatment.

Results:

Ninety patients were included in the study in total. Epley maneuver was carried out to all patients. Vertigo symptoms VAS (VASd) score (p < 0.001), nausea and vomiting VAS (VASnv) score (p < 0.001), and European Evaluation of Vertigo scale score (p < 0.001) of all patients showed a statistically significant decrease after Epley maneuver. A combination of dimenhydrinate and metoclopramide helped to reduce VASd (p = 0.048), VASnv (p = 0.031), and European Evaluation of Vertigo scale scores (p = 0.001) at a statistically significant level more than dimenhydrinate treatment alone.

Conclusions:

Epley maneuver may be applied to every patient with benign paroxysmal positional vertigo. Dimenhydrinate and/or metoclopramide helps to control patients’ symptoms whose symptoms remain despite Epley maneuver.

The evaluation of tinnitus and auditory brainstem response in benign paroxysmal positional vertigo accompanied by tinnitus

PURPOSE

The aim of this study is to investigate auditory brainstem response (ABR) in patients with benign paroxysmal positional vertigo (BPPV) accompanied by tinnitus and to suggest possible interpretative hypotheses.

METHODS

Ninety individuals were included in the study. Individuals were separated into three groups: patients reporting tinnitus with BPPV (Group I), patients with BPPV (Group II), and a control group. The ABR test was applied at a low and at a high rate.

RESULTS

For patients reporting tinnitus with BPPV, tinnitus was found to be localized in the ear affected by BPPV. Tinnitus disappeared after therapeutic interventions in 23 individuals with tinnitus. The difference between the Wave V  latency at high rate and Wave V  latency at a low rate in the affected ears of all individuals with BPPV (Groups I and II) was significantly long. In the affected ears of all BPPV patients, at a high rate of ABR, the absolute latency of the Wave III was found to be significantly longer than for the control group.

CONCLUSIONS

Individuals with BPPV showed prolonged latencies in affected ears in a high rate of ABR without the effect of tinnitus. High rate of ABR in individuals with BPPV can be used to obtain preliminary information in cases where ischemia in the auditory pathways is suspected in BPPV formation.

Betahistine add-on therapy for treatment of subjects with posterior benign paroxysmal positional vertigo: a randomized controlled trial

Introduction

Benign paroxysmal positional vertigo is a common vestibular disorder that accounts for one fifth of hospital admissions due to vertigo, although it is commonly undiagnosed.

Objective

To evaluate the effects of betahistine add-on therapy in the treatment of subjects with posterior benign paroxysmal positional vertigo.

Methods

This randomized controlled study was conducted in a population of 100 subjects with posterior benign paroxysmal positional vertigo. Subjects were divided into the Epley maneuver + betahistine group (group A) and Epley maneuver only (group B) group. Subjects were evaluated before and 1-week after the maneuver using a visual analog scale and dizziness handicap inventory

Results

One hundred subjects completed the study protocol. The Epley maneuver had an overall success rate of 95% (96% in group A; 94% in group B, p =  0.024). Groups A and B had similar baseline visual analog scale scores (6.98 ± 2.133 and 6.27 ± 2.148, respectively, p = 0.100). After treatment, the visual analog scale score was significantly lower in both groups, and was significantly lower in group A than group B (0.74 ± 0.853 vs. 1.92 ± 1.288, respectively, p = 0.000). The change in visual analog scale score after treatment compared to baseline was also significantly greater in group A than group B (6.24 ± 2.01 vs. 4.34 ± 2.32, respectively, p = 0.000). The baseline dizziness handicap inventory values were also similar in groups A and B (55.60 ± 22.732 vs. 45.59 ± 17.049, respectively, p = 0.028). After treatment, they were significantly lower in both groups. The change in score after treatment compared to baseline was also significantly greater in group A than group B (52.44 ± 21.42 vs. 35.71 ± 13.51, respectively, p = 0.000).

Conclusion

The Epley maneuver is effective for treatment of benign paroxysmal positional vertigo. Betahistine add-on treatment in posterior benign paroxysmal positional vertigo resulted in improvements in both visual analog scale score and dizziness handicap inventory.

The Impact of Betahistine versus Dimenhydrinate in the Resolution of Residual Dizziness in Patients with Benign Paroxysmal Positional Vertigo: A Randomized Clinical Trial

Objectives:

The aim of this study was to compare the effects of betahistine with dimenhydrinate on the resolution of residual dizziness (RD) of patients with benign paroxysmal positional vertigo (BPPV) after successful Epley maneuver.

Methods:

In this double-blind, randomized clinical trial, patients with posterior semicircular canal type of BPPV were included. After execution of the Epley maneuver, patients were assigned randomly to one group for 1 week: betahistine, dimenhydrinate or placebo. The primary outcomes were scores of the Dizziness Handicap Inventory (DHI) and the modified Berg balance scale (mBBS). All patients were asked to describe the characteristics of their subjective residual symptoms. Binary logistic regression analysis was performed to examine the predictors of improved RD. All analyses were conducted using SPSS 19.0.

Results:

In total, 117 patients (age range: 20-65 years) participated in this study. After the Epley maneuver, 88 participants had RD. After the intervention, 38 patients exhibited an improved RD. Less than 50% of participants in the three groups showed mild to moderate dizziness handicap. However, there was no significant difference between mBBS scores of groups before or after the intervention. Logistic regression was shown that patients with receiving betahistine were 3.18 times more likely to have no RD than the placebo group. Increasing age was associated with a decreased likelihood of improving RD ( P = .05).

Conclusion:

The analysis of data showed that the use of betahistine had more effect on improving RD symptoms. We recommended future studies using objective indicators of residual dizziness.

Approach to residual dizziness after successfully treated benign paroxysmal positional vertigo: effect of a polyphenol compound supplementation

Purpose

To assess if a polyphenol compound supplementation (Vertigoval^®) could improve residual dizziness earlier after benign paroxysmal positional vertigo (BPPV) and relieve patients from this disabling symptomatology.

Methods

In this prospective, multicentric study, 127 patients were randomized in the treatment group (TG), who received a 60-day supplementation, while 131 patients were randomized in the control group (CG), who did not receive any medication. The dizziness handicap inventory (DHI) score, static posturography, and the visual analog scale (VAS) for both dizziness (D-VAS) and nausea/vomit (N/V-VAS) were used as measures of outcome at baseline and after 30 and 60 days. Patients were asked about efficacy and tolerance to the treatment. Side effects were examined.

Results

A statistically significant greater decrease was established in the TG for DHI, D-VAS, and N/V-VAS compared to the CG. On the other hand, static posturography did not show statistical differences between the two groups, though a better clinical improvement after 60-day supplementation was shown in the TG in comparison to the CG. We counted mild side effects in only 2 patients. Most patients reported an excellent or good efficacy and tolerance to the treatment.

Conclusion

Residual dizziness is a frequent condition of unknown origin that manifests as persistent disabling imbalance after successful repositioning maneuvers for BPPV. The decreasing postural control can affect the quality of life, contributing to falling and psychological problems. The supplementation with the polyphenol compound used in our study is safe, manageable, and appeared to be able to reduce subjective symptoms and improve instability earlier, decreasing the risk of potential complications.

Effects of vestibular rehabilitation, with or without betahistine, on managing residual dizziness after successful repositioning manoeuvres in patients with benign paroxysmal positional vertigo: a protocol for a randomised controlled trial

INTRODUCTION

Benign paroxysmal positional vertigo (BPPV) is recognised as the leading cause of peripheral vertigo in adults. The canalith repositioning procedure (CRP) can be used for effective treatment of BPPV. However, some patients experience residual dizziness (RD) even after successful CRP, resulting in a significant negative impact on their daily function and quality of life. Exercise-based vestibular rehabilitation (VR) has been proven as an effective method for managing dizziness and has been applied in patients with various vestibular disorders. However, the efficacy of VR to specifically target RD post-BPPV is unknown. This study aims to investigate the efficacy of VR, compared with betahistine or VR plus betahistine treatment, in the treatment of patients experiencing RD after successful CRP.

METHODS AND ANALYSIS

A randomised single-blinded controlled trial will be carried out to determine the efficacy of VR compared with betahistine or VR plus betahistine treatment in mitigating RD and improving balance function. Patients with BPPV who experience RD after successful CRP will be recruited. Participants will be randomised into one of three groups to receive VR, betahistine or VR plus betahistine. There will be 61 participants in each group. The primary outcomes will be changes in the patient's daily function as measured by the Vestibular Activities and Participation questionnaire and balance ability assessed by computerised dynamic posturography. The secondary outcomes will be dizziness-related handicap, otolith function and duration of RD symptoms. Outcome measures will be noted at baseline and at 2, 4 and 8 weeks post-randomisation. This study has the potential to reduce unnecessary anti-vertigo drug prescriptions and may lead to a general consensus regarding the use of VR as a first-line treatment for RD in patients with BPPV.

ETHICS AND DISSEMINATION

This trial received ethical approval from the Institutional Review Board of Eye and ENT Hospital of Fudan University (reference number 2017046). The study results will be disseminated via peer-reviewed journals and conferences.

TRIAL REGISTRATION NUMBER

NCT03624283; Pre-results.

Comparing the Effects of Epley Maneuver and Cinnarizine on Benign Positional Paroxysmal Vertigo; A Randomized Clinical Trial

Background:

The fastest and safest treatment method of BPPV is repositioning maneuvers. In Iran, this methods are not widely used, and many physicians use medical therapy, despite their side effects, for management of BPPV.

Materials and Methods:

In this randomized clinical trial patients with BPPV were randomly allocated to Epley repositioning maneuver or Cinnarizine (25mg every 8 hours) for two weeks. The patients were evaluated for symptoms using visual analogue scale (VAS) scoring system before intervention, first and second weeks after intervention. In the second and third visitd the results of hallpike test was recorded for both groups.

Results:

43 patients with a mean age of 46.88±11.08 years in two Epley and Cinnarizine group underwent analysis. The mean VAS score for improvement of symptoms after intervention was 1.66±1.06 in Epley and 1.50±0.91 in Cinnarizine group (P=0.57).

Conclusion:

we found that there is no significant difference between Epley maneuver and Cinnarizine for treatment and controlling symptoms of BPPV.

Efficacy of Repositioning Therapy in Patients With Benign Paroxysmal Positional Vertigo and Preexisting Central Neurologic Disorders

With the exception of migraines, benign paroxysmal positional vertigo (BPPV) in patients with preexisting central neurologic disorders (CND) is rarely discussed in the literature. Demographic features of this patient group and the efficacy of repositioning therapy are still unknown. We hypothesized that a CND may alter the function of the central vestibular pathway, thus changing the pattern of BPPV and outcomes of repositioning. In this study, we enrolled 93 consecutive idiopathic BPPV patients and categorized them into two groups according to the presence or absence of a CND. In our series, 31.2% of BPPV cases had a CND. The most common associated CNDs were cerebrovascular disease and migraines. The two groups showed similar age distributions, canal involvement, success rates of repositioning, and cycles of treatment used to achieve complete resolution. The major differences were the proportion of females (89.7%) and a right-side predominance (75.9%) in the CND group. There was a trend of more residual dizziness (RD) after successful repositioning in the CND group, but the difference was not significant. The reason for the female and right-side predominance in the CND group is unclear. We concluded that the efficacy of repositioning therapy was excellent (with a success rate of 80.6% with one cycle and 93.5% within two cycles of treatment) for BPPV with or without a preexisting CND. Clinicians are encouraged to diagnose and treat BPPV in patients with a preexisting CND as early as possible to improve patients' quality of life, avoid complications, and reduce medical costs.

Advances in the diagnosis and treatment of benign paroxysmal positional vertigo

Benign paroxysmal positional vertigo (BPPV) (otolith disease) is the most common neurological and position change related vertigo, accounting for 17-20% of peripheral vertigo. BPPV occur in the elderly. The high incidence age for BPPC was 50 to 70 years and mostly in female. According to the different parts of the lesions, it is divided into anterior canal BPPV (AC-BPPV), posterior canal BPPV (PC-BPPV), horizontal canal BPPV (HC-BPPV). Studies have shown that the incidence of PC-BPPV was 86.36%, the incidence of HC-BPPV was 11.37%, the incidence rate of AC-BPPV was 2.27%. Treatment for PC-BPPV includes manual reduction, drug treatment, psychological treatment, and surgical treatment. Repositioning is the preferred method for the treatment of PC-BPPV with high effective rate and low risk. The mechanism is through the different changes of head position to make the otolith back to utricle. Many manual reduction methods have been reported in clinical treatment of PC-BPPV. With the increasing emphasis on the BPPV, a variety of new methods are being developed and designed.

Effectiveness of betahistine (48 mg/day) in patients with vestibular vertigo during routine practice: The VIRTUOSO study

Background

Vestibular vertigo is associated with substantially reduced quality of life. Betahistine is effective in improving vertigo-associated symptoms, with longer treatment periods leading to greater improvements; however, it is not known whether these effects persist after treatment cessation.

Methods

VIRTUOSO was a prospective, multinational, non-comparative, post-marketing observational programme investigating the effectiveness of betahistine (48 mg/day) and the course of vertigo after the discontinuation of treatment. Patients with vestibular vertigo who were prescribed 48 mg/day betahistine were enrolled in Russia and Ukraine. Treatment duration was up to 2 months, and patients were followed up for 2 months after discontinuation of betahistine. Efficacy endpoints included clinical response (assessed by change in vertigo severity), monthly attack frequency, and physician and patient grading of overall clinical response and improvement of vertigo-associated symptoms.

Results

Overall, 309 patients were enrolled and 305 completed the study. Clinical response was rated as good, very good or excellent in 74.1% of patients at end of treatment, with vertigo severity significantly decreased from baseline (p < 0.001). Monthly vertigo attack frequency decreased significantly during the 2 months of treatment (p < 0.001 from baseline) and further decreased during the 2-month follow-up (p < 0.001 from end of treatment). Overall, clinical response was graded as good or excellent by 94.4% of physicians and 95.4% of patients. Clinical improvement was considered either good or excellent by 82.6–90.5% of physicians and patients for nausea, vomiting and faintness. Only one adverse event was reported, with no serious adverse events.

Conclusion

Our findings suggest that betahistine (48 mg/day) therapy is effective in treating vertigo in routine clinical settings. The observed effects persisted for 2 months after treatment cessation, suggesting that betahistine may facilitate lasting vestibular compensation.

Clinical Practice Guideline: Benign Paroxysmal Positional Vertigo (Update)

Objective

This update of a 2008 guideline from the American Academy of Otolaryngology—Head and Neck Surgery Foundation provides evidence-based recommendations to benign paroxysmal positional vertigo (BPPV), defined as a disorder of the inner ear characterized by repeated episodes of positional vertigo. Changes from the prior guideline include a consumer advocate added to the update group; new evidence from 2 clinical practice guidelines, 20 systematic reviews, and 27 randomized controlled trials; enhanced emphasis on patient education and shared decision making; a new algorithm to clarify action statement relationships; and new and expanded recommendations for the diagnosis and management of BPPV.

Purpose

The primary purposes of this guideline are to improve the quality of care and outcomes for BPPV by improving the accurate and efficient diagnosis of BPPV, reducing the inappropriate use of vestibular suppressant medications, decreasing the inappropriate use of ancillary testing such as radiographic imaging, and increasing the use of appropriate therapeutic repositioning maneuvers. The guideline is intended for all clinicians who are likely to diagnose and manage patients with BPPV, and it applies to any setting in which BPPV would be identified, monitored, or managed. The target patient for the guideline is aged ≥18 years with a suspected or potential diagnosis of BPPV. The primary outcome considered in this guideline is the resolution of the symptoms associated with BPPV. Secondary outcomes considered include an increased rate of accurate diagnoses of BPPV, a more efficient return to regular activities and work, decreased use of inappropriate medications and unnecessary diagnostic tests, reduction in recurrence of BPPV, and reduction in adverse events associated with undiagnosed or untreated BPPV. Other outcomes considered include minimizing costs in the diagnosis and treatment of BPPV, minimizing potentially unnecessary return physician visits, and maximizing the health-related quality of life of individuals afflicted with BPPV.

Action Statements

The update group made strong recommendations that clinicians should (1) diagnose posterior semicircular canal BPPV when vertigo associated with torsional, upbeating nystagmus is provoked by the Dix-Hallpike maneuver, performed by bringing the patient from an upright to supine position with the head turned 45° to one side and neck extended 20° with the affected ear down, and (2) treat, or refer to a clinician who can treat, patients with posterior canal BPPV with a canalith repositioning procedure. The update group made a strong recommendation against postprocedural postural restrictions after canalith repositioning procedure for posterior canal BPPV. The update group made recommendations that the clinician should (1) perform, or refer to a clinician who can perform, a supine roll test to assess for lateral semicircular canal BPPV if the patient has a history compatible with BPPV and the Dix-Hallpike test exhibits horizontal or no nystagmus; (2) differentiate, or refer to a clinician who can differentiate, BPPV from other causes of imbalance, dizziness, and vertigo; (3) assess patients with BPPV for factors that modify management, including impaired mobility or balance, central nervous system disorders, a lack of home support, and/or increased risk for falling; (4) reassess patients within 1 month after an initial period of observation or treatment to document resolution or persistence of symptoms; (5) evaluate, or refer to a clinician who can evaluate, patients with persistent symptoms for unresolved BPPV and/or underlying peripheral vestibular or central nervous system disorders; and (6) educate patients regarding the impact of BPPV on their safety, the potential for disease recurrence, and the importance of follow-up. The update group made recommendations against (1) radiographic imaging for a patient who meets diagnostic criteria for BPPV in the absence of additional signs and/or symptoms inconsistent with BPPV that warrant imaging, (2) vestibular testing for a patient who meets diagnostic criteria for BPPV in the absence of additional vestibular signs and/or symptoms inconsistent with BPPV that warrant testing, and (3) routinely treating BPPV with vestibular suppressant medications such as antihistamines and/or benzodiazepines. The guideline update group provided the options that clinicians may offer (1) observation with follow-up as initial management for patients with BPPV and (2) vestibular rehabilitation, either self-administered or with a clinician, in the treatment of BPPV.

Residual Dizziness after Successful Repositioning Maneuver for Idiopathic Benign Paroxysmal Positional Vertigo: A Review

The benign paroxysmal positional vertigo (BPPV) is a vestibular disorder cause of vertigo. The BPPV may be corrected mechanically by repositioning maneuvers but even after successful maneuvers, some patients report residual dizziness for a certain period afterward. Early recognition and treatment might decrease the incidence of residual dizziness in patients with BPPV, especially in those patients with psychiatric comorbidities and in the elderly, lowering the risk of falling. Many pathogenetic hypotheses for residual dizziness are under debate. The purpose of this review was to identify, evaluate and review recent researches about possible causal factors involved in residual dizziness and the implications on clinical practice. A literature search was performed using different databases such as Pubmed and Scopus. The following search terms were used: residual dizziness, otolithic membrane and BPPV. The search found a total of 1192 titles, which were reduced to 963 after a procedure of de-duplication of the found titles. The research was then restricted to an interval of time comprised between 2000 and 2016 for a total of 800 titles. Among these titles, only those including the terms benign paroxysmal positional vertigo were considered eligible for this review. Only publications in English language were taken into consideration and we excluded those with not available abstract. Finally, 90 abstracts were obtained and critically evaluated by two different Authors, and additional studies were identified by hand searching from the references of artiche of interest. Only 53 were included in this work.

Diagnosis and treatment of benign paroxysmal positional vertigo in common clinical practice

Aim. To analyze typical medical practice in managing patients with benign paroxysmal positional vertigo (BPPV). Subjects and methods. 33 patients (5 men and 28 women; mean age, 58 years) with BPPV who had been referred for consultation to the Medical Diagnostic Department, Clinic of Nervous Diseases, I.M. Sechenov First Moscow State Medical University, regarding for vertigo, were examined. Information about the disease before visiting the clinic, such as the duration of vertigo, its pattern, and triggers, previously established diagnoses, prescribed treatment and its efficacy, concomitant diseases, was analyzed. Results. BPPV was not timely diagnosed in 93.9% of cases. The cause of vertigo was most commonly mistakenly assumed to be cerebrovascular disease (66.6%) and cervical spine pathology (15.1%). During a primary examination, none of the patients underwent positional tests (otoneurological examination) that formed the basis for the diagnosis of BPPV. Alternatively, 90.3% of cases underwent instrumental examination: magnetic resonance imaging of the brain, X-ray of the cervical spine, and ultrasonic duplex scanning of the brachiocephalic arteries. Ineffective diagnosis led to the choice of nonoptimal treatment tactics: instead of therapeutic repositioning maneuvers (RM), the patients received therapy with drugs, such as various vasoactive agents (84.8%), nootropic and chondroprotective drugs (12%), or muscle relaxants (9.1%). After BPPV was detected, all patients underwent curative RM, which resulted in regression of the disease. One-year follow-up of the patients showed that the therapeutic effect of RM persisted. Conclusion. Lack of effective and timely diagnosis of BPPV reflects physicians’ poor awareness that this condition is the most common cause of vestibular vertigo. The role of vascular and cervicogenic factors in the development of vertigo is overestimated. Most patients with BPPV undergo unreasonable examinations and receive ineffective treatment. It is necessary to raise awareness of BPPV among of physicians and to set up specialized centers for the management of patients with dizziness.

Betahistine for symptoms of vertigo

BACKGROUND

Vertigo is a symptom in which individuals experience a false sensation of movement. This type of dizziness is thought to originate in the inner ear labyrinth or its neural connections. It is a commonly experienced symptom and can cause significant problems with carrying out normal activities. Betahistine is a drug that may work by improving blood flow to the inner ear. This review examines whether betahistine is more effective than a placebo at treating symptoms of vertigo from different causes.

OBJECTIVES

To assess the effects of betahistine in patients with symptoms of vertigo from different causes.

SEARCH METHODS

The Cochrane ENT Information Specialist searched the Cochrane ENT Trials Register; Central Register of Controlled Trials (CENTRAL 2015, Issue 8); PubMed; EMBASE; CINAHL; Web of Science; ClinicalTrials.gov; ICTRP and additional sources for published and unpublished trials. We also contacted manufacturers and researchers in the field. The date of the search was 21 September 2015.

SELECTION CRITERIA

We included randomised controlled trials of betahistine versus placebo in patients of any age with vertigo from any neurotological diagnosis in any settings.

DATA COLLECTION AND ANALYSIS

We used the standard methodological procedures expected by Cochrane. Our primary outcome was the proportion of patients with reduction in vertigo symptoms (considering together the intensity, frequency and duration those symptoms).

MAIN RESULTS

We included 17 studies, with a total of 1025 participants; 12 studies were published (567 patients) and five were unpublished (458 patients). Sixteen studies including 953 people compared betahistine with placebo. All studies with analysable data lasted three months or less. The majority were at high risk of bias, but in some the risk of bias was unclear. One study, at high risk of bias, included 72 people with benign paroxysmal positional vertigo (BPPV) and compared betahistine with placebo; all patients also had particle repositioning manoeuvres. The studies varied considerably in terms of types of participants, their diagnoses, the dose of betahistine and the length of time it was taken for, the study methods and the way any improvement in vertigo symptoms was measured. Using the GRADE system, we judged the quality of evidence overall to be low for two outcomes (proportion of patients with improvement and proportion with adverse events).Pooled data showed that the proportion of patients reporting an overall reduction in their vertigo symptoms was higher in the group treated with betahistine than the placebo group: risk ratio (RR) 1.30, 95% confidence interval (CI) 1.05 to 1.60; 606 participants; 11 studies). This result should be interpreted with caution as the test for statistical heterogeneity as measured by the I(2) value was high.Adverse effects (mostly gastrointestinal symptoms and headache) were common but medically serious events in the study were rare and isolated: there was no difference in the frequency of adverse effects between the betahistine and placebo groups, where the rates were 16% and 15% respectively (weighted values, RR 1.03, 95% CI 0.76 to 1.40; 819 participants; 12 studies).Sixteen per cent of patients from both the betahistine and the placebo groups withdrew (dropped out) from the studies (RR 0.96, 95% CI 0.65 to 1.42; 481 participants; eight studies).Three studies looked at objective vestibular function tests as an outcome; the numbers of participants were small, techniques of measurement very diverse and reporting details sparse, so analysis of this outcome was inconclusive.We looked for information on generic quality of life and falls, but none of the studies reported on these outcomes.

AUTHORS' CONCLUSIONS

Low quality evidence suggests that in patients suffering from vertigo from different causes there may be a positive effect of betahistine in terms of reduction in vertigo symptoms. Betahistine is generally well tolerated with a low risk of adverse events. Future research into the management of vertigo symptoms needs to use more rigorous methodology and include outcomes that matter to patients and their families.

[Benign paroxysmal positional vertigo]

Benign paroxysmal positional vertigo (BPPV) is the most common cause of vestibular vertigo. It is caused by dislodged otoconia that enters the semicircular canals. Its main symptom is relapsing positional vertigo. The provocative tests, in particular the Dix-Hallpike maneuver, are used to confirm the diagnosis. In case of positive result of the test, one of the maneuvers is peformed depending on the affected semicircular canal, for instance the Epley maneuver. It is important to differentiate BPPV from the vertigo of central origin.

Features of Residual Dizziness after Canalith Repositioning Procedures for Benign Paroxysmal Positional Vertigo

Objectives

To assess factors related to residual dizziness (RD) in patients who underwent successful canalith repositioning procedures (CRPs) for benign paroxysmal positional vertigo (BPPV).

Study Design

Prospective cohort study.

Setting

Academic center.

Subjects and Methods

Ninety-seven consecutive patients with BPPV of the posterior semicircular canal were initially enrolled. Diagnosis was assessed according to clinical history and bedside evaluation. All patients were treated with CRPs until nystagmus disappeared. Three days after the successful treatment, presence of RD was investigated. If RD was present, patients were monitored every 3 days until the symptoms disappeared. Subjects who required ≥4 CRPs or who failed to meet the follow-up visit were excluded. The Dizziness Handicap Inventory (DHI) was obtained from patients at the time of diagnosis and at every subsequent visit.

Results

At the end of selection, 86 patients were included; 33 (38.36%) reported RD after successful treatment. A significant difference in the incidence of RD was observed in consideration of the age of the subjects ( P = .0003) and the DHI score at the time of diagnosis ( P < .001). A logistic regression analysis showed that the probability of RD occurrence increased with the increase of the emotional subdomain score of the DHI questionnaire.

Conclusion

RD is a common self-limited disorder, more frequent in the elderly, which may occur after the physical treatment for BPPV. The DHI score at the time of BPPV diagnosis represents a useful tool to quantify the impact of this vestibular disorder on the quality of life and to estimate the risk of RD after CRPs.

[Treatment of benign paroxysmal positional vertigo]

Benign paroxysmal positional vertigo (BPPV) is the most common peripheral vestibular disorder. BPPV is easily diagnosed by positioning tests and effectively treated by repositioning maneuvers. The authors focus on the treatment of BPPV, when different canals are affected, including canalo- and cupulolithiasias. Complications of BPPV and surgery of cases, resistant to conservative treatment, are also discussed.

Betahistine plus piracetam dual therapy versus betahistine monotherapy for peripheral vestibular vertigo: a confounder-corrected subanalysis of the OSVaLD study

INTRODUCTION

This subanalysis compared the efficacy of betahistine plus piracetam dual therapy versus betahistine monotherapy using data from OSVaLD, a 3 month, open-label, observational study conducted in 2272 patients with peripheral vestibular vertigo. Of the 1898 patients included in the original efficacy population, 1076 were from countries where betahistine plus piracetam dual therapy was prescribed to >1 patient; 114 of these 1076 patients (11%) received the dual therapy and 567 (53%) were treated with betahistine monotherapy; these patients were selected for analysis.

METHODS

Efficacy was assessed using the Dizziness Handicap Inventory (DHI) total and subscale scores. Propensity-score matching was used to correct potential differences in patient baseline characteristics between treatment groups. In addition, a subgroup analysis evaluated 103 patients treated with betahistine because of insufficient efficacy with their existing treatment.

RESULTS

In the propensity-score matched, total-population evaluation, improvements in the DHI total and subscale scores were numerically greater in the betahistine plus piracetam group (n = 88) versus the betahistine group (n = 89) (DHI total, -42.9 vs. -37.6, respectively; DHI physical, -12.1 vs. -10.4; DHI emotional, -13.5 vs. -13.2) and statistically significant for the DHI functional score (-17.3 vs. -14.0, respectively, p = 0.01). The percentage of patients with no impairment at final visit was 27% with betahistine and 47% with betahistine plus piracetam; odds ratio: 2.3, 95% confidence interval: 1.3-2.4 (p = 0.007). Similar results were obtained in the subgroup analyses for patients whose current vertigo treatment was insufficient. The overall incidence of adverse events was low and similar in both groups, and there were no discontinuations due to drug-related adverse events.

CONCLUSIONS

By using propensity-score matching, which controls for potential heterogeneity in patient baseline characteristics and small patient numbers, the results of this analysis suggest that combined betahistine and piracetam may be more effective than betahistine alone in patients with peripheral vestibular vertigo.

Use of betahistine in the treatment of peripheral vertigo

CONCLUSION

Clinical studies and meta-analyses demonstrated that betahistine is effective and safe in the treatment of Ménière's disease, BPPV (benign paroxysmal positional vertigo), vestibular neuronitis, and other types of peripheral vertigo.

OBJECTIVES

The goal of this paper is to review the pharmacological profile of betahistine and the evidence for its effectiveness and safety in the treatment of peripheral vertigo.

METHODS

Selection criteria for the publications on betahistine included randomized clinical trials that evaluated the effectiveness and safety of betahistine vs placebo or active control in the treatment of peripheral vertigo. Recent meta-analyses were also included. Databases searched included PubMed, the Cochrane Ear, Nose and Throat Disorders Group Trials Register, and ICTRP. The review also presents an update on the mechanisms of action, pharmacodynamics, and pharmacokinetics of betahistine.

RESULTS

Efficacy and safety of betahistine has been demonstrated in numerous clinical trials. The precise mechanism of action of betahistine is still not completely understood, but the clinical experience demonstrated the benefit of betahistine in different types of peripheral vertigo. In more than 40 years of clinical use, betahistine has shown an excellent safety profile with the usual dose range from 8-48 mg daily. According to clinical studies, betahistine 48 mg daily during 3 months is an effective and safe option for the treatment of peripheral vertigo.

Efficacy of computer-controlled repositioning procedure for benign paroxysmal positional vertigo

OBJECTIVES/HYPOTHESIS

To evaluate the short-term efficacy of the computer-controlled canalith repositioning procedure (CRP) for treatment of posterior canal benign paroxysmal positional vertigo (BPPV) compared with the current standard CRP.

STUDY DESIGN

Prospective case series.

METHODS

One hundred thirty-two patients diagnosed as having idiopathic posterior canal BPPV, with an age range of 28 to 86 years (mean 56 years), 47 men and 85 women, were treated with computer-controlled CRP mimicking the Epley maneuver. Resolution of vertigo and nystagmus on the Dix-Hallpike test at 1-week follow-up after treatment was the main outcome measure to assess the efficacy of treatment.

RESULTS

At 1-week follow-up after treatment with computer-controlled CRP, 108 (81.8%) of 132 patients had complete resolution of vertigo and nystagmus, nine (6.8%) had resolution of vertigo but presence of nystagmus, and 15 (11.4%) had provoked vertigo and nystagmus on the Dix-Hallpike test. The 81.8% success rate was comparable to those who received current standard CRP treatment in randomized controlled trials at about 80%. No significant adverse effects or complications occurred in the patients treated with computer-controlled CRP, aside from two patients (1.5%) with conversion into lateral canal BPPV.

CONCLUSIONS

Computer-controlled CRP is effective for the treatment of posterior canal BPPV, with a success rate similar to those treated with the Epley maneuver, and is safe and easy to perform on patients.

High stimulus rate brainstem auditory evoked potential in benign paroxysmal positional vertigo

The objective of this study is to use high (49/s) and low (9/s) stimulation rates of the BAEP to investigate the possible mechanism responsible for BPPV. A total of 81 patients (55 women and 26 men, mean age ± SD = 54.6 ± 15.0) with idiopathic BPPV, as well as 106 control subjects (70 women and 36 men, mean age ± SD = 51.2 ± 16.3) participated in the study. The results of high (49/s) and low (9/s) stimulation rates of the BAEP test were compared and analyzed. The difference in BAEP wave I peak latencies between low and high stimulation rate (DPL I) and BAEP wave I peak latency in high stimulation (HPL I) of affected ears (0.24 ± 0.14 and 1.91 ± 0.21 ms) in BPPV patients were significantly prolonged when compared with the controls (0.10 ± 0.08 and 1.76 ± 0.18 ms) and unaffected ears (0.12 ± 0.10 and 1.82 ± 0.21 ms) (p < 0.001). The abnormal rate of DPL I in the affected ear (52/83, 62.65 %) was significantly higher than that in the unaffected ear (7/79, 8.86 %) and the normal left ear (4/106, 3.77 %). We suggest that ischemia of the inner ear might be one of the causes of BPPV and that DPL I may be used to assess the ischemic degree in subjects over 20 years old.

Vestibular suppressants after canalith repositioning in benign paroxysmal positional vertigo

OBJECTIVES/HYPOTHESIS

To investigate the characteristics of residual symptoms and to evaluate the effects of adjuvant vestibular suppressants on residual symptoms after successful canalith repositioning procedures (CRPs).

STUDY DESIGN

Individual randomized controlled trial.

METHODS

One hundred fifty patients with idiopathic benign paroxysmal positional vertigo who achieved successful CRPs on initial visit participated in this study. Dizziness Handicap Inventory (DHI) questionnaires were completed before CRPs. All study populations were divided into three groups after successful CRPs on the initial visit day: the medication (V) group (treated with a vestibular suppressant [dimenhydrinate 50 mg per day]), the placebo (P) group, and the no medication (N) group. One week after successful CRPs, residual symptoms were checked and repeated DHI questionnaires were completed to compare residual symptoms.

RESULTS

Among the 138 patients who did not show positional nystagmus at follow-up, 67 (48.5%) complained of residual symptoms. The presence of residual symptoms was more prevalent in the P and N group compared with the V group (P = .035, P = .017, respectively). The most frequent residual symptom was lightheadedness (n = 42). Moreover, in the V group, lightheadedness was significantly reduced compared with the P group (P = .029). However, in the analysis of DHI, total and subscale scores did not differ across the three groups before or after successful CRP.

CONCLUSIONS

Vestibular suppressants significantly reduced residual symptoms compared to both placebo and no medication after CRP. However, there was no significant reduction in DHI score compared with the control group, suggesting that the residual symptoms could not be evaluated by DHI score alone.

Effectiveness of the Epley's maneuver performed in primary care to treat posterior canal benign paroxysmal positional vertigo: study protocol for a randomized controlled trial

BACKGROUND

Vertigo is a common medical condition with a broad spectrum of diagnoses which requires an integrated approach to patients through a structured clinical interview and physical examination. The main cause of vertigo in primary care is benign paroxysmal positional vertigo (BPPV), which should be confirmed by a positive D-H positional test and treated with repositioning maneuvers. The objective of this study is to evaluate the effectiveness of Epley's maneuver performed by general practitioners (GPs) in the treatment of BPPV.

METHODS/DESIGN

This study is a randomized clinical trial conducted in the primary care setting. The study's scope will include two urban primary care centers which provide care for approximately 49,400 patients. All patients attending these two primary care centers, who are newly diagnosed with benign paroxysmal positional vertigo, will be invited to participate in the study and will be randomly assigned either to the treatment group (Epley's maneuver) or to the control group (a sham maneuver). Both groups will receive betahistine. Outcome variables will be: response to the D-H test, patients' report on presence or absence of vertigo during the previous week (dichotomous variable: yes/no), intensity of vertigo symptoms on a Likert-type scale in the previous week, total score on the Dizziness Handicap Inventory (DHI) and quantity of betahistine taken.

DISCUSSION

Positive results from our study will highlight that treatment of benign paroxysmal positional vertigo can be performed by trained general practitioners (GPs) and, therefore, its widespread practice may contribute to improve the quality of life of BPPV patients.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT01969513.