BPPV and MIGRAINE. Speaker Disclosure. Inner Ear Anatomy. Format of Presentation. Inner Ear Anatomy. Infrared Video-oculography

Transcription

1 BPPV and MIGRAINE Diagnosis and Treatment of the Two Most Common Causes of Dizziness Scott K Sanders, MD, PhD Coalition of Advanced Practice Nurses of Indiana Annual Convention Speaker Disclosure No Financial Relationships to Disclose April 11, 2015 Format of Presentation Inner Ear Anatomy Brief Background Anatomy Recording eye movements BPPV Symptoms Diagnosis of Multiple BPPV Types Treatment Migraine Symptoms Treatment Inner Ear Anatomy Infrared Video-oculography

2 Left-beat Nystagmus BPPV Benign Paroxysmal Positional Vertigo Positional Vertigo of BPPV First described by Barany in : Dix and Hallpike described the test (Dix-Hallpike position) which helps identify BPPV as the etiology of episodic vertigo 1992: John Epley describes the canalithiasis theory of BPPV and the canalith repositioning procedure Epley a quack John Epley, MD, ENT from Portland, OR 1980 ENT meeting demonstrated his maneuver - audience walked out 1983 submitted journal article to Otology for publication - rejected defied established theory 1992 journal article published in JAAO - 30 patients suffering BPPV with 100% cure rate Despite publication, many doctors rejected his work and local colleagues stopped referring patients for the next several years Eventually, his canalith repositioning maneuver was accepted and became known as the Epley maneuver BPPV Otoconia Crystals Due to otoconia (canaliths, crystals, rocks) from the utricle of the inner ear which break free and travel into a semicircular canal Move in the fluid-filled semicircular canal with changes in head position, mitigated by gravity Results in abnormal nerve stimulation causing nystagmus Results in brief vertigo associated with changes in head position Laying down, getting up from, or rolling over in bed Looking up or down, bending over

3 Crystals Displaced into Posterior Canal Causes of BPPV Primary or idiopathic (50% 70%) Dr. Tim Hain As a rule of thumb, about 50% of dizziness is caused by BPPV by the age of 80 Secondary (30% 50%) Head trauma (7% 17%) Viral labyrinthitis (15%) Ménière's disease (5%) Migraines (< 5%) Inner ear surgery (< 1%) Types of BPPV Posterior Canal (PC) Horizontal Canal (HC) Anterior Canal (AC) Cupulolithiasis ( stuck crystals ) Posterior Canal (PC) BPPV Checking for PC BPPV Right Dix-Hallpike Position Dix-Hallpike position Start with sitting upright on a table Turn head 45 degrees to the right or left Lay back quickly with neck extended 30 degrees below horizontal If unable, try side lying position

4 Dix-Hallpike Position for Left PC BPPV Dix-Hallpike Position for Right PC BPPV Watch for unwinding nystagmus upon returning to sit Treatment of PC BPPV (Modified) Epley Maneuver Canalith Repositioning Maneuvers (CRM) (modified) Epley Semont Half Somersault NOT vestibular suppressant medications (meclizine, diazepam, phenergan) or habituation exercises (Cawthorne- Cooksey, Brandt-Daroff) Turn head to left and move opposite direction for Left PC BPPV Shown for Right PC BPPV (Modified) Epley Maneuver Semont Maneuver for Right PC BPPV Shown for Right PC BPPV Turn head to left and move opposite direction for Left PC BPPV Opposite for left PC BPPV

5 Half Somersault for Right PC BPPV The Goal of CRMs Audiology & Neurotology 2012;2:16-23 Put the crystals back in the utricle Head turn to left elbow in C for Left PC BPPV Enzymes (dark cells) that dissolve loose crystals Checking for HC BPPV Lay supine with neck flexed 30 degrees Turn head or body right, then left Horizontal Canal (HC) BPPV If otoconia in horizontal canal, see horizontal nystagmus Geotropic R-beat in head Right L-beat in head Left HC Testing Position Can also test HC by lying on back with head turn to right or left Left Horizontal Canal BPPV

6 Determining Side of HC BPPV Ewald s second law - excitatory stimuli produce a greater response than inhibitory stimuli With HC BPPV RIGHT EAR - excitatory response occurs in the right HC when the right ear is down and inhibitory response occurs in the right HC when the left ear is down LEFT EAR - excitatory response occurs in the left HC with the left ear is down and inhibitory response occurs in the left HC when the right ear is down Therefore, the side with loose otoliths in the HC elicits the greater nystagmus when turned toward the ground Why is Choosing the Correct Side Important? With Left HC BPPV, treatment is to roll to the Right With Right HC BPPV, treatment is to roll to the Left Rolling the wrong way could push the crystals against the cupula where they could become stuck ( cupulolithiasis ) Treatment for HC BPPV Lempert Roll for Right HC BPPV Head/Body Roll Away from Affected Ear (Baloh)-Lempert Roll BBQ Roll Log Roll Alternatives Roll opposite direction for Left HC BPPV Vannucchi-Asprella Gufoni Appiani (patient unable to lay on back or stomach) Lempert Roll for Right HC BPPV BPPV - Posterior vs Horizontal Right Posterior Canal BPPV Left Horizontal Canal BPPV Roll opposite direction for Left HC BPPV Hallpike Position Right Supine Head Right, then Head Left

7 BPPV Summary Canal Head Position Nystamus Canalith Repositioning Maneuver Posterior Hallpike Upbeat Rotational modified Epley, Semont Horizontal Supine Right-beating in Head Right and Leftbeating in Head Left Lempert Roll Anterior Hallpike Downbeat Rotational modified Epley from deep Hallpike Canalithiasis Cupulolithiasis Cupulolithiasis Cupulolithiasis Cupula becomes gravity-sensitive Difference in characteristics from Canalithiasis Longer-lasting More resistant to repositioning maneuvers - only 50% success Checking for Cupulolithiasis - HC Lay supine with neck flexed 30 degrees Turn head or body right, then left Apogeotropic nystagmus Left-beating with head to the right Right-beating with head to the left Greater slow phase velocity nystagmus ear up is the involved ear Cupulolithiasis

8 Choosing Correct Side Treatment of Cupulolithiasis - HC Goal in treatment: Convert to Canalithiasis Forced prolonged positioning unaffected side 12 hours Head thrusts toward unaffected ear repeated 10x Vannucci-Asprella - 4 step maneuver repeated 10x Inverted Gufoni (lie to affected side nose up) BPPV Recurrence More About BPPV 30% in first year, then 15%/year 50/50 chance of recurrence at 3 years Home canalith repositioning instructions Benign paroxysmal positional vertigo and its management Management of BPPV Med Sci Monit, 2007 Jun 204 patients Posterior Canal - 80% Horizontal Canal - 9.5% Anterior Canal - 3% Bilateral Posterior Canal - 5% Multicanal - 2.5% Appropriate repositioning maneuver 92% success rate Med Sci Monit, 2007 Jun CRM (such as Epley maneuver) 92% success rate No longer should be using medications (no meclizine or diazepam or phenergan) No longer should be performing habituation exercises (Brandt-Daroff, Cawthorn-Cooksey)

9 CRM Failure Post-CRM Restrictions Not Necessary J Otolaryngol 1996; 25:121-5 Vestibular habituation exercises (Brandt-Daroff; Cawthorne-Cooksey) - next to last case scenario Surgical canal plugging - last case scenario Otolaryng Head Neck Surg 2000; 122:440-4 Rev Bras Otorrinolaringol 2005 Nov-Dec; 71(6): Eur Arch Otorhinolaryngol (2005) 262: Otology and Neurology 29(5) August 2008:706-9 Neurology 2008; 70: Otolaryng Head and Neck Surg. Feb1, 2010 v 142(2); Case Case 52 year old woman who has started sleeping with her head elevated on 3 pillows because she usually develops vertigo laying down in bed Vertigo lasts seconds and may also occur when she gets up from bed, looks up or looks down She was evaluated in the ER and given meclizine, but this just made her sleepy Case Case Examination showed transient upbeat rotational nystagmus lasting 15 seconds, when placed in the left Hallpike position She underwent a modified Epley maneuver, but continued to experience positional vertigo Repeat Hallpike positioning to either side was negative for BPPV of the posterior canal

10 Case - Body R, then Body L Case What happened? Does the patient need an MRI? What is the diagnosis? Case May have had multi-canal BPPV (both PC and HC canal on the left) at presentation OR, during the modified Epley maneuver, the otoliths went from the PC to the HC - Canal Conversion Migraine and Dizziness 15% occurrence Tx: Perform Lempert roll to the right Approximately 60-80% of patients who Migraine simply causes more vertigo than any other condition - Timothy Hain, MD, PhD experience recurrent vertigo without hearing loss have migraines - Brandtberg and Furman, 2005

11 Migraine-associated Dizziness AAO-HNS meeting 2011 The #1 cause of dizziness Under-recognized Often have mild or no concurrent headaches, but usually have a headache history ( sinus headache = migraine) Migraine-related dizziness gigantic topic huge as a cause of dizziness dominates our practice 15 times more common than Meniere s Migraine-associated Dizziness Migraine-associated Dizziness Symptoms Dizziness that is often difficult to describe Morning predominance of symptoms Wide range of duration Visual motion sensitivity is common Grocery shopping is difficult (big box stores) May have light and/or noise sensitivity Usually have a history of headaches, but often no concurrent headaches Diagnosis Rule out other causes - vestibular function testing usually adequate if neurologic exam and hearing is normal Treatment Eliminating any triggers Preventative medications Migraine-associated Dizziness Non-food Triggers Treatment Identification and modification/ elimination of triggers Medications Tricyclic amitriptyine* nortriptyline* SSRI venlafaxine Anti-hypertensive verapamil* propranolol Anti-seizure valproic acid* topirimate* gabapentin Prognosis - Excellent! Inadequate sleep Weather changes Hormone changes Stress Allergies

12 Food Triggers Tricyclic Antidepressants nortriptyline - 10, 25, 50, 75, 100 mg MSG Nutrasweet Packaged meats Nuts Alcohol amitriptyline - 10, 25, 50, 75, 100 mg Take once daily 1-2 hours before bedtime Side effects 3 D s - Drowsiness (amitrip > nortrip), Dry mouth, weird Dreams other less common - weight gain, heartburn, palpitations, moodiness/angry Anti-Hypertensive Anti-epileptics valproic acid (ER) 125, 250, 500 mg verapamil (SR) 120, 180, 240, 300, 360 mg Take once daily at breakfast Side effects constipation rarely peripheral edema, palpitations Take once daily Side effects - weight gain, hair loss, tremor, drowsiness, nausea Avoid in women of child bearing age (neural tube defects) topirimate (has ER form available now) 25, 50, 100, 200 mg Take twice daily Side effects - paresthesias, taste alteration, weight loss, confusion ( dopamax ), reduced sweating, kidney stones - rare angle closure glaucoma Monitoring Medication Treatment Dosing - start low and go slow Improvement delayed for 3-4 weeks after starting and after dose changes If not working, try alternative If no symptoms for 6 months, consider tapering/stopping Neuhauser criteria for migrainous vertigo (2005) Recurrent vestibular symptoms Migraine headache meeting criteria (current or previous) At least one of the following migrainous symptoms during at least two of the attacks migraine-type headache visual or other aura photophobia phonophobia Other causes ruled out

13 Migraine-associated Vertigo (MV) - in Curr Pain Headache Rep, 2007 June A strong association exists between vertigo and migraine with MV being the most common cause of spontaneous (nonpositional) vertigo Symptoms can be quite variable among patients and within individual patients over time, creating a diagnostic challenge. MV generally presents with attacks of spontaneous or positional vertigo lasting seconds to days with associated migrainous symptoms. proper studies of optimal MV management are just beginning. Concluding Remarks BPPV BPPV Overdiagnosed Look for spontaneous nystagmus (vestibular neuritis/labyrinthitis) Diagnose (R/L) side and affected semicircular canal(s) Treat with CRM (not meclizine or habituation exercises) Be certain that the provoked nystagmus fits the characteristic features and is of the correct type for the head position 2-3 second latency second duration upbeat rotational for Dix-Hallpike - PC horizontal for head supine/right/left - HC Other Causes of Positional Vertigo Migraine is #1 *Migraine Multiple Sclerosis Arnold-Chiari Malformation Drug Effects Cerebellar Stroke or Degeneration Intracranial Tumor Neurovascular Compression of CN VIII Uncompensated Unilateral Vestibular Loss If BPPV is unlikely/ruled out and there is no hearing loss or neurologic symptoms in the setting of recurrent dizziness/vertigo - ALWAYS consider migraine, even if no headaches

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