Diagnosis and treatment of dizziness in outpatient practice

Objective: to study the causes of dizziness and instability in patients during an outpatient specialized appointment and to analyze and improve typical management tactics for these patients.
Patients and methods. In 2009 to 2014, neurologists, dizziness specialists, examined 300 patients (122 men and 178 women) aged 18 to 85 years, who complained of dizziness and instability. Prior to the examination, the patients had been diagnosed as having dyscirculatory encephalopathy (46%), vertebrobasilar insufficiency (30%), cervical osteochondrosis (12%), and vegetative dystonia (7%). 
Results and discussion. The examination established the causes of dizziness: benign paroxysmal positional vertigo (BPPV) (34%), phobic postural instability (22%), multiple sensory insufficiency (15%), Meniere's disease (7%), migraine-associated vertigo (5%), vestibular neuronitis (4%), acute cerebrovascular accident (4%), and other diseases (9%). In accordance with the established diagnosis, adequate treatment which could completely eliminate or substantially reduce the magnitude of dizziness in the majority of cases was performed. 

The paper describes two clinical cases (BPPV and Meniere's disease). Betahistine dihydrochloride (vesticap, betaserc) were most commonly used in a dose of 48 mg/day to treat vestibular vertigo. It gives the results of comparative treatment (with vesticap or betaserc) for vestibular vertigo in 62 patients.
The authors note the low level of diagnosis and effective treatment in patients with dizziness in outpatient practice. They show the expediency of a specialized examination, the efficiency and safety of current treatments, including medication therapy with betahistine dihydrochloride (betaserc and vesticap) and rehabilitation on a stabiligraphic platform with biofeedback, for vestibular vertigo. 

1. Brandt Т, Dieterich М. Vertigo and dizziness: common complains. London: Springer; 2004. 208 p.

2. Brandt T. Vertigo. Its Multisensory Syndromes. London: Springer; 2000. 504 p.

3. Craighero F, Casselman JW, Safronova MM, et al. Sudden onset vertigo: imaging work-up. J Radiol. 2011 Nov;92(11):972–86. doi: 10.1016/j.jradio.2011.09.001. Epub 2011 Oct 20.

4. Jahn K, Dieterich M. Recent advances in the diagnosis and treatment of balance disorders. J Neurol. 2011 Dec;258(12):2305–8. doi: 10.1007/s00415-011-6286-4. Epub 2011 Oct 27.

5. Strupp M, Brandt T. Current treatment of vestibular, ocular motor disorders and nystagmus. Ther Adv Neurol Disord. 2009 Jul;2(4):223–39. doi: 10.1177/1756285609103120.

6. Strupp M, Thurtell MJ, Shaikh AG, et al. Pharmacotherapy of vestibular and ocular motor disorders, including nystagmus. J Neurol. 2011 Jul;258(7):1207–22. doi: 10.1007/s00415-011-5999-8. Epub 2011 Apr 2.

7. Kanashiro AM, Pereira CB, Melo AC, Scaff M. Diagnosis and treatment of the most frequent vestibular syndromes. Arq Neuropsiquiatr. 2005 Mar;63(1):140–4. Epub 2005 Apr 13.

8. Morris AE, Lutman ME, Yardley L. Measuring outcome from vestibular rehabilitation, part II: refinement and validation of a new self-report measure. Int J Audiol. 2009 Jan;48(1):24–37. doi: 10.1080/14992020802314905.

9. Alvarenga GA, Barbosa MA, Porto CC. Benign paroxysmal positional vertigo without nystagmus: diagnosis and treatment.

10. Braz J Otorhinolaryngol. 2011 Nov–Dec;77(6):799–804.

11. Do YK, Kim J, Park CY, et al. The effect of early canalith repositioning on benign paroxysmal positional vertigo on recurrence. Clin Exp Otorhinolaryngol. 2011 Sep;4(3):113–7. doi: 10.3342/ceo.2011.4.3.113. Epub 2011 Sep 6.

12. Lempert T, Neuhauser H, Daroff RB. Vertigo as a symptom of migraine. Ann N Y Acad Sci. 2009 May;1164:242–51. doi: 10.1111/j.1749-6632.2009.03852.x.

13. Halmagyi GM, Curthoys IS. A clinical sign of canal paresis. Arch Neurol. 1988 Jul;45(7):737–9.

14. Fife TD. Benign paroxysmal positional vertigo. Semin Neurol. 2009 Nov;29(5):500–8. doi: 10.1055/s-0029-1241041. Epub 2009 Oct 15.

15. Парфенов ВА, Замерград МВ. Головокружение в неврологической практике. Неврологический журнал. 2005;(1):4–11. [Parfenov VA, Zamergrad MV. Vertigo in neurological practice. Nevrologicheskii zhurnal. 2005;(1):4–11. (In Russ.)].

16. Парфенов ВА, Замерград МВ, Мельников ОА. Головокружение диагностика, лечение, распространенные диагностические ошибки. Учебное пособие. Москва: Медицинское информационное агентство; 2011. 190 с. [Parfenov VA, Zamergrad MV, Mel'nikov OA. Golovokruzhenie diagnostika, lechenie, rasprostranennye diagnosticheskie oshibki. Uchebnoe posobie. [Vertigo diagnosis, treatment, common diagnostic errors. The tutorial]. Moscow: Meditsinskoe informatsionnoe agentstvo; 2011. 190 p.].

17. Bronstein AM, Gresty MA, Luxon LM. Phobic postural vertigo. Neurology. 1997 Nov;49(5):1480–1.

18. Замерград МВ. Головокружение: роль сосудистых факторов. Эффективная фармакотерапия. Неврология и психиатрия. 2013;4(45):4–5. [Zamergrad MV. Vertigo: the role of vascular factors. Effective pharmacotherapy. Nevrologiya i psikhiatriya. 2013;4(45):4–5. (In Russ.)].

19. Парфенов ВА, Абдулина ОВ, Замерград МВ. Периферическая вестибулопатия под маской инсульта. Неврологический журнал. 2005;(6):28–32. [Parfenov VA, Abdulina OV, Zamergrad MV. Peripheral vestibulopathy under the mask of stroke. Nevrologicheskii zhurnal. 2005;(6):28–32. (In Russ.)].

20. Замерград МВ, Антоненко ЛМ. Посттравматическое головокружение. Неврологический журнал. 2012;(2):4–10 [Zamergrad MV, Antonenko LM. Post-traumatic vertigo. Nevrologicheskii zhurnal. 2012;(2):4–10. (In Russ.)].

21. Brandt Т, Huppert I, Hecht J, et al. Benign paroxysmal positioning vertigo: a long-term follow-up (6–17 years) of 125 patients. Acta Otolaryngol. 2006 Feb;126(2):160–3.

22. Redon C, Lopez C, Bernard-Demanze L, et al. Betahistine treatment improves the recovery of static symptoms in patients with unilateral vestibular loss. J Clin Pharmacol. 2011 Apr;51(4):538–48. doi: 10.1177/0091270010369241. Epub 2010 Oct 12.

23. Brandt Т, Huppert Т, Нufner K, et al. Longterm course and relapses of vestibular and balance disorders. Restor Neurol Neurosci. 2010;28(1):69–82. doi: 10.3233/RNN-20100504.

24. Антоненко ЛМ, Бестужева НВ, Парфенов ВА. Применение препаратов бетагистина при головокружении. Медицинский совет. 2014;(18):34–40. [Antonenko LM, Bestuzheva NV, Parfenov VA. The use of betahistine in vertigo. Meditsinskii sovet. 2014;(18):34–40. (In Russ.)].

25. Lacour M, Sterkers O. Histamine and betahistine in the treatment of vertigo. Elucidation of mechanisms of action. CNS Drugs. 2001;15(11):853–70.

26. Gates GA. Meniere's disease review 2005. J Am Acad Audiol. 2006 Jan;17(1):16–26.

27. Lezius F, Adrion C, Mansmann U, et al. High-dosage betahistine dihydrochloride between 288 and 480 mg/day in patients with severe Meniere's disease: a case series. Eur Arch Otorhinolaryngol. 2011 Aug;268(8):1237–40. doi: 10.1007/s00405-011-1647-2. Epub 2011 May 29.

28. Minor LB, Schessel DA, Carey JP. Meniere's disease. Curr Opin Neurol. 2004 Feb;17(1):9–16.

29. Замерград МВ, Мельников ОА. Болезнь Меньера. Неврологический журнал. 2011;(1):5–8. [Zamergrad MV, Mel'nikov OA. Meniere's disease. Nevrologicheskii zhurnal. 2011;(1):5–8. (In Russ.)].

30. Strupp M, Hupert D, Frenzel С, et al. Long-term prophylactic treatment of attacks of vertigo in Meniere’s disease comparison of a high with a low dosage of betahistine in an open trial. Acta Otolaryngol. 2008 May;128(5):520–4.

31. doi: 10.1080/00016480701724912.

32. Oosterveld WJ. Betahistine dihydrochloride in the treatment of vertigo of peripheral vestibular origin. A double-blind placebo-controlled study. J Laryngol Otol. 1984 Jan;98(1):37–41.