Acute vestibular vertigo: modern methods for diagnosis and treatment

Acute vestibular vertigo is most commonly due to the disorders of the peripheral vestibular system: vestibular neuronitis, Meniere's disease, benign paroxysmal positional vertigo, and vestibular migraine. An acute cerebrovascular accident or transient ischemic attack in the vertebrobasilar arterial system is the significantly less common cause of acute vestibular vertigo. In our country, vestibular system disorders remain difficult to diagnose. Many patients with peripheral nervous system affection are misdiagnosed with cerebrovascular disease, vertebrobasilar insufficiency, and cervical osteochondrosis. The development of acute vestibular vertigo in vestibular neuronitis may be accompanied by high blood pressure in patients with arterial hypertension, which is often interpreted by doctors as a manifestation of cerebrovascular disease. However, absence of signs of a stroke on neuroimaging of the brain does not help determine the correct diagnosis, in which case, as a rule, vertebrobasilar insufficiency is diagnosed.

In this situation, it is especially important to conduct a clinical neurovestibular examination, including assessment of nystagmus, Halmagyi head thrust maneuver, assessment of skew deviation, as well as a caloric test, which makes it possible to establish a correct diagnosis. Modern diagnostic methods and effective therapeutic regimens have been developed for each of the nosological forms. A comprehensive approach to the management of patients with vertigo is most preferable. The conducted studies showed a significant decrease in the severity of vertigo in the treatment of patients with unilateral vestibular neuritis, Meniere's disease and other disorders of the peripheral and central vestibular system with a low-dose combination of cinnarizine 20 mg + dimenhydrinate 40 mg. This drug is well tolerated and does not depress vestibular compensation. The comparison of the effectiveness of the low-dose combination of cinnarizine + dimenhydrinate and betahistine dihydrochloride showed that treatment of vestibular neuritis with the combination drug results in more significant regress of acute vestibular vertigo than the treatment with betahistine. Treatment of acute vestibular vertigo proved to be more effective when the drug therapy was combined with vestibular gymnastics.

1. Edlow J.A., Gurley K.L., Newman-Toker D.E. A new diagnostic approach to the adult patient with acute dizziness. J Emerg Med. 2018;54(4):469–483. https://doi.org/10.1016/j.jemermed.2017.12.024.

2. Saber Tehrani A.S., Kattah J.C., Kerber K.A., Gold D.R., Zee D.S., Urrutia V.C., Newman-Toker D.E. Diagnosing stroke in acute dizziness and vertigo: pitfalls and pearls. Stroke. 2018;49(3):788–795. https://doi.org/10.1161/STROKEAHA.117.016979.

3. Kulesh A.A., Dyomin D.A., Guseva A.L.,Vinogradov O.I., Parfyonov V.A. Vestibular vertigo in emergency neurology. Russian Neurological Journal. 2021;(4):50–59. (In Russ.) https://doi.org/10.30629/2658-7947-2021-26-4-50-59.

4. Parfenov V.A., Abdulina O.V., Zamergrad M.V. Peripheral vestibulopathy under the guise of a stroke. Nevrologicheskii Zhurnal. 2005;(6): 28–32. (In Russ.)

5. Parfenov V.A., Zamergrad M.V., Melnikov O.A. Vertigo: diagnosis and treatment, common diagnostic mistakes. Мoscow; 2019. 208 p. (In Russ.)

6. Strupp M., Dlugaiczyk J., Ertl-Wagner B.B., Rujescu D., Westhofen M., Dieterich M. Vestibular disorders – diagnosis, new classification and treatment. Dtsch Arztebl Int. 2020;117(17):300–310. https://doi.org/10.3238/arztebl.2020.0300.

7. Antonenko L.M. Drug and non-drug treatments of vertigo. Meditsinskiy Sovet. 2021;(2):39–44. (In Russ.) https://doi.org/10.21518/2079701X-2021-2-39-44.

8. Antonenko L.M. Current aspects of the treatment of different types of vertigo. Meditsinskiy Sovet. 2021;(19):91–98. (In Russ.) https://doi.org/10.21518/2079-701X-2021-19-91-98.

9. Novotný M., Kostrica R. Fixed combination of cinnarizine and dimenhydrinate versus betahistine dimesylate in the treatment of Menière’s disease: a randomized, double-blind, parallel-group clinical study. Int Tinnitus J. 2002;8(2):115–123. Available at: https://pubmed.ncbi.nlm.nih.gov/14763223.

10. Novotný M., Bognar-Steinberg I., Baumann W. Fixed combination of cinnarizine and dimenhydrinate versus betahistine dimesylate in the treatment of Menière’s disease: post hoc non-inferiority analysis of a prospective, randomized, double-blind study. Arch Sensol Neurootol. 2011. Available at: https://neurootology.org/archives/649.

11. Scholtz A.W., Hahn A., Stefflova B., Medzhidieva D., Ryazantsev S.V., Paschinin A. et al. Efficacy and Safety of a Fixed Combination of Cinnarizine 20 mg and Dimenhydrinate 40 mg vs Betahistine Dihydrochloride 16 mg in Patients with Peripheral Vestibular Vertigo: A Prospective, Multinational, Multicenter, Double-Blind, Randomized, Noninferiority Clinical Trial. Clin Drug Investig. 2019;39(11):1045–1056. https://doi.org/10.1007/s40261-019-00858-6.

12. Adamec I., Krbot S.M., Handzic J., Habek M. Incidence, seasonality and comorbidity in vestibular neuritis. Neurol Sci. 2015;36(1):91–95. https://doi.org/10.1007/s10072-014-1912-4.

13. Jeong S.H., Kim H.J., Kim J.S. Vestibular Neuritis. Semin Neurol. 2013:33(3):185–194. https://doi.org/10.1055/s-0033-1354598.

14. Malayala S.V., Raza A. A Case of COVID-19-Induced Vestibular Neuritis. Cureus. 2020;12(6):e8918. https://doi.org/10.7759/cureus.8918.

15. Han W., Wang D., Wu Y., Fan Z., Guo X., Guan Q. Correlation between vestibular neuritis and cerebrovascular risk factors. Am J Otolaryngol. 2018;39(6):751–753. https://doi.org/10.1016/j.amjoto.2018.08.006.

16. Greco A., Macri G.F., Gallo A., Fusconi M., De Virgilio A., Pagliuca G. et al. Is vestibular neuritis an immune related vestibular neuropathy inducing vertigo? J Immunol Res. 2014;2014:459048. https://doi.org/10.1155/2014/459048.

17. Büki B., Hanschek M., Jünger H. Vestibular neuritis: Involvement and longterm recovery of individual semicircular canals. Auris Nasus Larynx. 2017;44(3):288–293. https://doi.org/10.1016/j.anl.2016.07.020.

18. Taylor R.L., McGarvie L.A., Reid N., Young A.S., Halmagyi G.M., Welgampola M.S. Vestibular neuritis affects both superior and inferior vestibular nerves. Neurology. 2016;87(16):1704–1712. https://doi.org/10.1212/WNL.0000000000003223.

19. Strupp M., Magnusson M. Acute unilateral vestibulopathy. Neurol Clin. 2015;33(3):669–685. https://doi.org/10.1016/j.ncl.2015.04.012.

20. Parfenov V.A. Vestibular neuronitis. Meditsinskiy Sovet. 2021;(2):31–36. (In Russ.) https://doi.org/10.21518/2079-701X-2021-2-31-36.

21. Palchun V.T., Makoeva A.A., Gusev A.L. Dizziness and vertigo associated with vestibular neuronitis: the approaches to the diagnostics and treatment. Vestnik Oto-Rino-Laringologii. 2018;(3):4–10. (In Russ.) https://doi.org/10.17116/otorino20188334.21.

22. Parfenov V.A., Antonenko L.M. Major diseases manifesting by vestibular vertigo: Treatment and rehabilitation. Neurology, Neuropsychiatry, Psychosomatics. 2015;(2):56–60. (In Russ.) https://doi.org/10.14412/20742711-2015-2-56-60.

23. Аntonenko L.M. Diagnosis, treatment, and rehabilitation in patients with dizziness and cognitive impairment. Neurology, Neuropsychiatry, Psychosomatics. 2017;(3):76–80. (In Russ.) https://doi.org/10.14412/20742711-2017-3-76-80.

24. Carmona S., Martínez C., Zalazar G., Moro M., BatuecasCaletrio A., Luis L. et al. The Diagnostic Accuracy of Truncal Ataxia and HINTS as Cardinal Signs for Acute Vestibular Syndrome. Front Neurol. 2016;7:125. https://doi.org/10.3389/fneur.2016.00125.

25. Krishnan K., Bassilious K., Eriksen E., Bath P.M., Sprigg N., Brækken S.K. et al. Posterior circulation stroke diagnosis using HINTS in patients presenting with acute vestibular syndrome: A systematic review. Eur Stroke J. 2019;4(3):233–239. https://doi.org/10.1177/239698731984370.

26. Parfenov V., Golyk V., Matsnev E., Morozova S.V., Melnikov O.A., Antonenko L.M. et al. Effectiveness of betahistine (48 mg/day) in patients with vestibular vertigo during routine practice: The VIRTUOSO study. PLoS ONE. 2017;12(3):e0174114. https://doi.org/10.1371/journal.pone.0174114.

27. Fishman J.M., Burgess C., Waddell A. Corticosteroids for the treatment of idiopathic acute vestibular dysfunction (vestibular neuritis). Cochrane Database Syst Rev. 2011;11(5):CD008607. https://doi.org/10.1002/14651858.CD008607.pub2.

28. Hegemann S.C.A., Wenzel A. Diagnosis and Treatment of Vestibular Neuritis/Neuronitis or Peripheral Vestibulopathy (PVP)? Open Questions and Possible Answers. Otol Neurotol. 2017;38(5);626–631. https://doi.org/10.1097/MAO.0000000000001396.

29. Goudakos J.K., Markou K.D., Psillas G., Vital V., Tsaligopoulos M. Corticosteroids and Vestibular Exercises in Vestibular Neuritis. JAMA Otolaryngol Head Neck Surgery. 2014;140(5):434–440. https://doi.org/10.1001/jamaoto.2014.48.

30. Hillier S.L., McDonnell M. Vestibular rehabilitation for unilateral peripheral vestibular dysfunction. Cochrane Database Syst Rev. 2011;16(2):CD005397. https://doi.org/10.1002/14651858.CD005397.pub3.

31. Antonenko L.M., Parfenov V.A. A specialized approach to diagnosing and treating vertigo. Neurology, Neuropsychiatry, Psychosomatics. 2016;(1):56–60. (In Russ.) https://doi.org/10.14412/2074-2711-2016-1-56-60.

32. Powell G., Derry-Sumner H., Rajenderkumar D., Rushton S., Sumner P. Persistent postural perceptual dizziness is on a spectrum in the general population. Neurology. 2020;94(18):1–10. https://doi.org/10.1212/WNL.0000000000009373.

33. Teh С.S., Prepageran N. The impact of disease duration in persistent postural-perceptual dizziness (PPPD) on the quality of life, dizziness handicap and mental health. J Vestib Res. 2022;32(4):373–380. https://doi.org/10.3233/VES-210087.

34. Antonenko L.M., Zastenskaya E.N. Persistent postural-perceptual dizziness: current approaches to diagnosis and treatment. Neurology, Neuropsychiatry, Psychosomatics. 2019;(4):136–140. (In Russ.) https://doi.org/10.14412/2074-2711-2019-4-136-140.

35. Zastenskaya E.N., Antonenko L.M., Barinov A.N. Comorbidities and their correction in patients with persistent postural perceptual dizziness. Clinical Practice in Pediatrics. 2020;(1):48–52. (In Russ.) https://doi.org/10.20953/1817-7646-2020-1-48-52.

36. Zastenskaya E.N., Antonenko L.M. Optimizing the management of patients with persistent postural perceptual dizziness and migraine. Meditsinskiy Sovet. 2022;(23):94–100. (In Russ.) https://doi.org/10.21518/2079701X-2022-16-23-94-100.

37. Bedenko A.S., Antonenko L.M., Barinov A.N. Metabolic Disorders in the Pathogenesis of Various Causes of Dizziness and Instability. Annals of Russian Academy of Medical Sciences. 2020;(6):605–608. (In Russ.) https://doi.org/10.15690/vramn1244.

38. Bedenko A.S., Antonenko L.M. Vitamin D and homocysteine in benign paroxysmal positional vertigo. Meditsinskiy Sovet. 2022;16(2):63–69. (In Russ.) https://doi.org/10.21518/2079-701X-2022-16-2-63-69.

39. von Brevern M., Bertholon P., Brandt T., Fife T., Imai T., Nuti D., NewmanToker D. Benign paroxysmal positional vertigo: diagnostic criteria. J Vestib Res. 2015;25(3-4):105–117. https://doi.org/10.3233/VES-150553.

40. Bhattacharyya N., Gubbels S.P., Schwartz S.R., Edlow J.A., El-Kashlan H., Fife T. et al. Clinical practice guideline: benign paroxysmal positional vertigo (Update). Otolaryngol Head Neck Surg. 2017;156(3):403–416. https://doi.org/10.1177/0194599816689667.

41. Rhim G. Serum Vitamin D and Long-Term Outcomes of Benign Paroxysmal Positional Vertigo. Clin Exp Otorhinolaryngol.2019;12(3):273–278. https://doi.org/10.21053/ceo.2018.00381.

42. Lempert T., Olesen J., Furman J., Waterston J., Barry Seemungal B., Carey J. et al. Vestibular migraine: Diagnostic criteria. J Vestib Res. 2012;22(4):167–172. https://doi.org/10.3233/VES-2012-0453.

43. Lempert T., von Brevern M. Vestibular Migraine. Neurol Clin. 2019;37(4):695–706. https://doi.org/10.1016/J.NCL.2019.06.003.

44. Ayzenberg I., Katsarava Z., Sborowski A., Chernysh M., Osipova V., Tabeeva G. et al. Lifting the Burden. The prevalence of primary headache disorders in Russia: a countrywide survey. Cephalalgia. 2012;32(5): 373–381. https://doi.org/10.1177/0333102412438977.

45. Golovacheva V.A., Golovacheva A.A., Antonenko L.M. Migraine in children and adolescents: modern principles of diagnostics and treatment. Neurology, Neuropsychiatry, Psychosomatics. 2021;13(6):111–116. (In Russ.) https://doi.org/10.14412/2074-2711-2021-6-111-116.

46. Azimova Yu.E., Amelin A.V., Alferova V.V., Artemenko A.R., Akhmadeeva L.R., Golovacheva V.A. et al. Clinical guidelines “Migraine”. Zhurnal Nevrologii i Psikhiatrii imeni S.S. Korsakova. 2022;(1221-3):4–36. (In Russ.) https://doi.org/10.17116/jnevro20221220134.

47. Tabeeva G.R. Headaches in general medical practice. Terapevticheskii Arkhiv. 2022;94(1):114–121. (In Russ.) https://doi.org/10.26442/00403660.2022.01.201325.

48. Kiryanova E.A., Тabeeva G.R. Hormone therapy for menstrual-associated migraine: pros and cons. Neurology, Neuropsychiatry, Psychosomatics. 2022;14(1):69–75. (In Russ.) https://doi.org/10.14412/2074-2711-2022-1-69-75.

49. Sergeev A.V., Tabeeva G.R., Filatova E.G., Amelin A.V., Akhmadeeva L.R., Lebedeva E.R. et al. Application of a new biological pathogenetic therapy of migraine in clinical practice: expert consensus of the Russian Headache Research Society. Neurology, Neuropsychiatry, Psychosomatics. 2022;14(5):109–116. (In Russ.) https://doi.org/10.14412/2074-2711-2022-5-109-116.

50. Perez A.J., Dinchen G., Theresa C., George S. Topiramate for the Management of Vestibular Migraine. Otolaryngol Head Neck Surgery. 2013;149(2):238. https://doi.org/10.1177/0194599813496044a291.

51. Liu F., Ma T., Che X., Wang Q., Yu S. The efficacy of venlafaxine, flunarizine, and valproic acid in the prophylaxis of vestibular migraine. Front Neurol. 2017;8:524. https://doi.org/10.3389/fneur.2017.00524.

52. Parfenov V.A. Ménière’s disease and chronic cerebrovascular diseases. Meditsinskiy Sovet. 2021;(19):35–40. (In Russ.) https://doi.org/10.21518/2079-701X-2021-19-35-40.

53. Lopez-Escamez J.A., Carey J., Chung W.H., Goebel J.A., Magnusson M., Mandalà M. et al. Diagnostic criteria for Menière’s disease. J Vestib Res. 2015;25(1):1–7. https://doi.org/10.3233/VES-150549.

54. Adrion C., Fischer C.S., Wagner J., Gurkov R., Mansmann U., Strupp M. Efficacy and safety of betahistine treatment in patients with Meniere’s disease: primary results of a long term, multicentre, double blind,randomised, placebo controlled, dose defining trial (BEMED trial). BMJ. 2016;352:h6816. https://doi.org/10.1136/bmj.h6816.