Benign Paroxysmal Positional Vertigo (BPPV) in the neurologist’s cabinet

Sketch64201437.jpegIt is a common disorder and a frequent cause of urgent consultation, even for a neurologist practicing in a cabinet. The disorder is characterized by stereotypical short-lasting episodes of vertigo due to rapid changes in head positions. It is often an idiopathic disease but it can also associate with other ORL disorders. When the history (presence of vegetative symptoms) and clinical findings are typical (geotropic or ageotropic habituating stereotyped nystagmus after a latency with Dix-Hallpike and Roll test maneuvers) there is no need for other investigations (such as brain MRI). The Dix-Hallpike test can detect posterior and anterior canal BPPV, the Roll test can detect horizontal canal BPPV. The presence of other neurological signs or symptoms (headache, oculomotor palsy, auditory symptoms, sensory or motor signs, limb ataxia or severe gait ataxia) are not at all typical of BPPV and should conduct to other diagnosis.
In my memory, I have a 50% rate success with treatment by the modified Epley’s maneuver. This rate seems to correspond or it is slightly lower than what clinical studies report. Actually, I usually have a so good feeling when the Epley’s maneuver works! The patient who felt very sick recovers so fast and he/she is so grateful. It is quite rare for a neurologist to have in the cabinet a so immediate curative intervention. However, one study (Sacco et al. J Emerg Med 2014, Jan 21) questioned the benefits of such maneuvers in the emergency department as the satisfaction of the patients and the persistence of symptoms were, after two hours, similar for the group of patients treated with maneuvers and the group treated with drugs. I always thought that during maneuvers, there should be also some sort of psychological intervention but when the maneuver works, the positional nystagmus (that previously was there before the maneuver) completely disappears.

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