A set of related medical disorders that lack a proper classification system and diagnostic criteria is like a society without laws. The result is incoherence at best, chaos at worst. For this reason, the International Classification of Headache Disorders (ICHD) is arguably the single most important breakthrough in headache medicine over the last 50 years. The ICHD identifies and categorizes more than a hundred different kinds of headache in a logical, hierarchal system. Even more important, it has provided explicit diagnostic criteria for all of the headache disorders listed. The ICHD quickly became universally accepted, and criticism of the classification has been minor relative to that directed at other disease classification systems. Over the 20 years following publication of the first edition of the ICHD, headache research has rapidly accelerated despite sparse allocation of resources to that effort. In summary, the ICHD has attained widespread acceptance at the international level and has substantially facilitated both clinical research and clinical care in the field of headache medicine.

International Classification of Headache Disorders

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.

/pdf/clinical-practice-guideline-benign-paroxysmal-positional-4c8374bric.pdf

Clinical practice guideline: Benign paroxysmal positional vertigo

Objectives: To examine the prevalence and incidence, clinical presentation, societal impact and comorbid conditions of benign paroxysmal positional vertigo (BPPV) in the general population. Methods: Cross-sectional, nationally representative neurotological survey of the general adult population in Germany with a two stage sampling design: screening of 4869 participants from the German National Telephone Health Interview Survey 2003 (response rate 52%) for moderate or severe dizziness or vertigo, followed by validated neurotological interviews (n = 1003; response rate 87%). Diagnostic criteria for BPPV were at least five attacks of vestibular vertigo lasting Results: BPPV accounted for 8% of individuals with moderate or severe dizziness/vertigo. The lifetime prevalence of BPPV was 2.4%, the 1 year prevalence was 1.6% and the 1 year incidence was 0.6%. The median duration of an episode was 2 weeks. In 86% of affected individuals, BPPV led to medical consultation, interruption of daily activities or sick leave. In total, only 8% of affected participants received effective treatment. On multivariate analysis, age, migraine, hypertension, hyperlipidaemia and stroke were independently associated with BPPV. Conclusion: BPPV is a common vestibular disorder leading to significant morbidity, psychosocial impact and medical costs.

https://jnnp.bmj.com/content/jnnp/78/7/710.full.pdf

Epidemiology of benign paroxysmal positional vertigo. A population-based study

Objectives: To examine the prevalence and incidence, clinical presentation, societal impact and comorbid conditions of benign paroxysmal positional vertigo (BPPV) in the general population. Methods: Cross-sectional, nationally representative neurotological survey of the general adult population in Germany with a two stage sampling design: screening of 4869 participants from the German National Telephone Health Interview Survey 2003 (response rate 52%) for moderate or severe dizziness or vertigo, followed by validated neurotological interviews (n = 1003; response rate 87%). Diagnostic criteria for BPPV were at least five attacks of vestibular vertigo lasting < 1 min without concomitant neurological symptoms and invariably provoked by typical changes in head position. In a concurrent validation study (n = 61) conducted in two specialised dizziness clinics, BPPV was detected by our telephone interview with a specificity of 92% and a sensitivity of 88% (positive predictive value 88%, negative predictive value 92%). Results: BPPV accounted for 8% of individuals with moderate or severe dizziness/vertigo. The lifetime prevalence of BPPV was 2.4%, the 1 year prevalence was 1.6% and the 1 year incidence was 0.6%. The median duration of an episode was 2 weeks. In 86% of affected individuals, BPPV led to medical consultation, interruption of daily activities or sick leave. In total, only 8% of affected participants received effective treatment. On multivariate analysis, age, migraine, hypertension, hyperlipidaemia and stroke were independently associated with BPPV. Conclusion: BPPV is a common vestibular disorder leading to significant morbidity, psychosocial impact and medical costs.

Epidemiology of benign paroxysmal positional vertigo: a population based study. Editorial Commentary

Background Balance dysfunction can be debilitating and can lead to catastrophic outcomes such as falls. The inner ear vestibular system is an important contributor to balance control. However, to our knowledge, the prevalence of vestibular dysfunction in the United States and the magnitude of the increased risk of falling associated with vestibular dysfunction have never been estimated. The objective of this study was to determine the prevalence of vestibular dysfunction among US adults, evaluate differences by sociodemographic characteristics, and estimate the association between vestibular dysfunction and risk of falls. Methods We included data from the 2001-2004 National Health and Nutrition Examination Surveys, which were cross-sectional surveys of US adults aged 40 years and older (n = 5086). The main outcome measure was vestibular function as measured by the modified Romberg Test of Standing Balance on Firm and Compliant Support Surfaces. Results From 2001 through 2004, 35.4% of US adults aged 40 years and older (69 million Americans) had vestibular dysfunction. Odds of vestibular dysfunction increased significantly with age, were 40.3% lower in individuals with more than a high school education, and were 70.0% higher among people with diabetes mellitus. Participants with vestibular dysfunction who were clinically symptomatic (ie, reported dizziness) had a 12-fold increase in the odds of falling. Conclusions Vestibular dysfunction, as measured by a simple postural metric, is common among US adults. Vestibular dysfunction significantly increases the likelihood of falls, which are among the most morbid and costly health conditions affecting older individuals. These data suggest the importance of diagnosing, treating, and potentially screening for vestibular deficits to reduce the burden of fall-related injuries and deaths in the United States.

https://jamanetwork.com/journals/jamainternalmedicine/articlepdf/773517/ioi90006_938_944.pdf

Disorders of Balance and Vestibular Function in US Adults: Data From the National Health and Nutrition Examination Survey, 2001-2004

Objective: To assess the prevalence of migrainous vertigo in patients with migraine and in patients with vertigo according to explicit diagnostic criteria that are presented for discussion. Methods: The authors prospectively evaluated 200 consecutive patients from a dizziness clinic and 200 patients from a migraine clinic for migrainous vertigo based on the following criteria: 1) recurrent vestibular symptoms (rotatory/positional vertigo, other illusory self or object motion, head motion intolerance); 2) migraine according to the criteria of the International Headache Society (IHS); 3) at least one of the following migrainous symptoms during at least two vertiginous attacks: migrainous headache, photophobia, phonophobia, visual or other auras; and 4) other causes ruled out by appropriate investigations. In addition, the authors compared the prevalence of migraine according to the IHS criteria in the dizziness clinic group with a sex- and age-matched control group of 200 orthopedic patients. Results: The prevalence of migraine according to the IHS criteria was higher in the dizziness clinic group (38%) compared with the age- and sex-matched control group (24%, p Conclusion: These results substantiate the epidemiologic association between migraine and vertigo and indicate that migrainous vertigo affects a significant proportion of patients both in dizziness and headache clinics.

The interrelations of migraine, vertigo, and migrainous vertigo.

Objective: The purpose of this study was to determine the prevalence and incidence of vestibular vertigo in the general population and to describe its clinical characteristics and associated factors. Methods: The neurotologic survey had a two-stage general population sampling design: nationwide modified random digit dialing sampling for participation in the German National Telephone Health Interview Survey 2003 (response rate 52%) with screening of a random sample of 4,869 participants for moderate or severe dizziness or vertigo, followed by detailed neurotologic interviews developed through piloting and validation (n = 1,003, response rate 87%). Diagnostic criteria for vestibular vertigo were rotational vertigo, positional vertigo, or recurrent dizziness with nausea and oscillopsia or imbalance. Vestibular vertigo was detected by our interview with a specificity of 94% and a sensitivity of 88% in a concurrent validation study using neurotology clinic diagnoses as an accepted standard (n = 61). Results: The lifetime prevalence of vestibular vertigo was 7.8%, the 1-year prevalence was 5.2%, and the incidence was 1.5%. In 80% of affected individuals, vertigo resulted in a medical consultation, interruption of daily activities, or sick leave. Female sex, age, lower educational level, and various comorbid conditions, including tinnitus, depression, and several cardiovascular diseases and risk factors, were associated with vestibular vertigo in the past year in univariate analysis. In multivariable analysis, only female sex, self-reported depression, tinnitus, hypertension, and dyslipidemia had an independent effect on vestibular vertigo. Conclusions: Vestibular vertigo is common in the general population, affecting more than 5% of adults in 1 year. The frequency and health care impact of vestibular symptoms at the population level have been underestimated.

Epidemiology of vestibular vertigo: a neurotologic survey of the general population.

Objective: To investigate the epidemiology of migrainous vertigo (MV) in the general population by assessing prevalence, clinical features, comorbid conditions, quality of life, and health care utilization. Methods: We screened a representative sample of the adult population in Germany (n = 4,869) for moderate or severe dizziness/vertigo and followed up with validated neurotologic telephone interviews (n = 1,003). Diagnostic criteria for MV were as follows: 1) recurrent vestibular vertigo; 2) migraine according to the International Headache Society; 3) migrainous symptoms during at least two vertiginous attacks (migrainous headache, photophobia, phonophobia, or aura symptoms); and 4) vertigo not attributed to another disorder. In a concurrent validation study (n = 61) the interviews had a sensitivity of 84% and a specificity of 94% for vestibular vertigo and 81% and 100% for migraine. Results: The lifetime prevalence of MV was 0.98% (95% CI 0.70 to 1.37), the 12-month prevalence 0.89% (95% CI 0.62 to 1.27). Spontaneous rotational vertigo was reported by 67% of participants with MV while 24% had positional vertigo. Twenty-four percent always experienced headaches with their vertigo. Logistic regression analysis comparing participants with MV with dizziness-free migraineurs showed an independent association with coronary heart disease but not with sex, age, migrainous aura, education, stroke, hypertension, hyperlipidemia, body mass index, or depression. Age-adjusted health-related quality of life scores (SF-8 Health Survey) were consistently lower in participants with MV compared to dizziness-free controls. Two thirds of participants with MV had consulted a doctor but only 20% of these were diagnosed with MV. Conclusions: Migrainous vertigo is relatively common but underdiagnosed in the general population and has considerable personal and healthcare impact.

M. von Brevern

Papers

Epidemiology of benign paroxysmal positional vertigo. A population-based study

Epidemiology of benign paroxysmal positional vertigo: a population based study. Editorial Commentary

The interrelations of migraine, vertigo, and migrainous vertigo.

Epidemiology of vestibular vertigo: a neurotologic survey of the general population.

Migrainous vertigo Prevalence and impact on quality of life