Vestibular migraine or BPPV?
Reviewed by Sangeeta Maini & Bhaskar Ram

There are close similarities between benign paroxysmal positional vertigo (BPPV) and vestibular migraine (VM) as both can be presented by positional nystagmus. Though BPPV remains the commonest cause of pure positional vertigo, VM can mimic this condition. This study is the retrospective review of 12 patients from a cohort of 126 vertiginous patients with positional nystagmus diagnosed as BPPV and referred to the vestibular clinic over a period of five years in a university hospital. The selected 12 patients were provisionally diagnosed as BPPV but did not respond to repositioning manoeuvres. All patients were subjected to full history-taking and videonystagmography (VNG), at least three attempts of repositioning manoeuvres and MRI brain with contrast. On failure of improvement, empirical trial of Topiramate tablets was prescribed to all 12 patients with gradual increasing dose from 25mg -100mg until complete improvement of vertigo and positional nystagmus was noted. Ten of the 12 patients showed improvement in vertigo and resolution of positional nystagmus with recurrence of symptoms when, after six months of complete improvement, any trial of topiramate was gradually discontinued. In 10 out of 12 patients, the improvement was directly related to the effect of the topiramate and was not related to any spontaneous improvement of the BPPV. However, in two out of 12 patients who failed to improve after receiving the medication for one month, even with increasing the dose to 100mg per day, frequent repositioning exercises finally resulted in symptom resolution. The study reinforces the fact that VM, even with no history of classical migraine headache, can mimic BPPV. However, the diagnosis of BPPV should certainly be revisited if there was no improvement on anti-migraine medication. Also please be aware that both conditions can co-exist.

Vestibular migraine and benign paroxysmal positional vertigo, close presentation dilemma.
Mahrous MM.
ACTA OTO-LARYNGOLOGICA
2020;140(9):741-4.