Benign Recurrent Vertigo

Benign recurrent vertigo describes repeated attacks of spontaneous vertigo, lasting minutes to days, with no hearing loss and no other neurological signs between attacks. It is now regarded as closely related to, or identical with, vestibular migraine in most patients, which is the commonest cause of spontaneous recurrent vertigo in adults. It affects about 1 to 3 percent of the population, more often women, usually starting between 20 and 50 years.

• Vestibular migraine criteria: at least 5 episodes of moderate or severe vestibular symptoms lasting 5 minutes to 72 hours; a current or past history of migraine; and migraine features (headache, photophobia, phonophobia, visual aura) with at least half of the attacks.
• Triggers: stress, sleep deprivation, hormonal changes (menstruation), certain foods (aged cheese, chocolate, red wine, caffeine, monosodium glutamate), dehydration, weather change, visual motion stimuli.
• Attacks may be accompanied by nausea, vomiting, motion intolerance and imbalance between episodes. Mild hearing fluctuation or tinnitus can occur but progressive hearing loss argues for Meniere disease.
• Prognosis is variable: attacks may reduce over years; some develop chronic imbalance or anxiety.
• Diagnosis is by exclusion: BPPV, Meniere disease, vestibular neuritis, posterior circulation transient ischaemic attack or stroke, cardiac arrhythmia, orthostatic hypotension, acoustic neuroma, multiple sclerosis, perilymph fistula, autoimmune inner ear disease, anxiety and panic disorder, medication effect.

• Spontaneous (or positional) vertigo (spinning) or dizziness, often with nausea, vomiting, sensitivity to head movement, light and noise, unsteadiness, and headache before, during or after (headache is absent in up to half of attacks).
• Duration: seconds (rare), minutes, hours up to 3 days; typically with complete recovery between attacks.
• Examination between attacks is normal. During an attack: horizontal torsional nystagmus, abnormal head impulse test, gait unsteadiness; central signs may appear.
• Red flags (central cause): sudden onset with new severe headache; double vision, dysarthria, facial numbness or weakness, limb ataxia or weakness; vertical or direction changing nystagmus; failed HINTS examination (normal head impulse test, direction changing nystagmus, skew deviation); inability to stand; age over 60 with vascular risk factors; neck pain after trauma (vertebral dissection); progressive unilateral hearing loss or tinnitus (acoustic neuroma); loss of consciousness (arrhythmia); persistent vertigo beyond 3 days.

• Clinical, based on history, examination and exclusion of other causes.
• Examination: neurological and cranial nerve examination, nystagmus (with and without fixation), HINTS during attack, Dix-Hallpike and supine roll tests for BPPV, Romberg and gait, orthostatic blood pressure, cardiac auscultation and pulse.
• Pure tone audiogram (normal in vestibular migraine; low frequency sensorineural loss in Meniere disease).
• ECG and ambulatory monitoring for syncope or palpitations; full blood count, glucose, electrolytes, thyroid function, vitamin B12.
• MRI brain with internal auditory canals: for any central sign, asymmetric hearing loss, atypical course, abnormal examination, or first episode with vascular risk factors; urgent MRI with diffusion sequences if stroke is suspected (CT is insensitive for posterior fossa).
• Vestibular testing (video head impulse test, caloric tests) in specialist centres.
• Differentials: BPPV (brief positional episodes), Meniere disease (hearing loss, tinnitus, aural fullness lasting 20 minutes to 12 hours), vestibular neuritis (single prolonged episode), TIA, panic disorder, persistent postural perceptual dizziness.

• Acute attack (short term only, maximum 48 to 72 hours, as prolonged suppression delays central compensation):
  • Prochlorperazine 5 to 10 mg orally three times daily, or 12.5 mg intramuscularly, or 3 mg buccal twice daily.
  • Cyclizine 50 mg orally three times daily, or promethazine 25 mg orally at night and 10 mg during the day.
  • Ondansetron 4 to 8 mg orally or intravenously for nausea.
  • Diazepam 2 mg orally three times daily for up to 3 days for severe attacks (sedation; avoid in older adults).
  • Migraine specific treatment for the headache: sumatriptan 50 to 100 mg orally at attack onset (maximum 300 mg per day) where vascular contraindications are absent, plus paracetamol or an NSAID.
  • Hydration and rest in a dark quiet room.
• Lifestyle and trigger control: regular sleep and meals, adequate hydration, limit caffeine and alcohol, identify and avoid food triggers using a diary, stress management, regular aerobic exercise.
• Preventive therapy if attacks occur more than twice a month or are disabling (assess response after 8 to 12 weeks at a therapeutic dose; use the migraine prophylaxis agent that suits comorbidities):
  • Propranolol 40 mg orally twice daily, increased to 80 mg twice daily (avoid in asthma, heart block, bradycardia, depression).
  • Amitriptyline 10 mg orally at night, increased by 10 mg every 1 to 2 weeks to 50 mg (sedation, anticholinergic effects, QT prolongation, cardiac disease caution).
  • Venlafaxine modified release 37.5 mg daily, increased after 1 week to 75 mg daily (monitor blood pressure).
  • Topiramate 25 mg at night, increased by 25 mg weekly to 50 mg twice daily (cognitive effects, paraesthesia, kidney stones, teratogenic; contraception advised).
  • Flunarizine 5 to 10 mg orally at night where available (depression, weight gain, extrapyramidal effects).
  • Lamotrigine 25 mg daily increased slowly to 100 to 200 mg daily (specialist).
  • Candesartan 8 to 16 mg daily or sodium valproate (avoid in women of childbearing potential) are other options.
• Betahistine 16 mg orally three times daily is used for Meniere disease and some other vestibular disorders but has limited evidence in vestibular migraine.
• Vestibular rehabilitation exercises with a physiotherapist for persistent imbalance between attacks.
• Cognitive behavioural therapy for anxiety, avoidance behaviour and persistent postural perceptual dizziness.
• Safety advice: no driving or operating machinery during or immediately after attacks, and discuss licensing rules; avoid heights; use sitting and lying down at onset.
• Review at 4 to 8 weeks, then every 3 to 6 months; reassess the diagnosis if hearing loss develops or central signs appear. Refer to ENT or neurology for atypical features, abnormal MRI, progressive hearing loss, or failure of two preventive agents.