I am currently treating a patient with left posterior canalithiasis. I have performed the Epley on numerous occassions, the patient will test negative at the next treatment and be fine for up to 2 weeks, then it will come back spontaneously. Last treatment, she was negative to Dix Hallpike, but during Brandt Daroff ex, nystagmus returned. What am I missing?
My physician (Dr. Adrian Priesol mass eye and ear, Boston)...believes that those symptoms can be caused by BVVP or migraine. If the manuvers do not correct the symptoms....you might want to think about a migraine preventitive..
As you know BPPV is a common problem affecting 10% of people over 60. What a lot of people don't realize is that is it also a chronic problem. The calcium crystals (otoconia) that cause BPPV are normal parts of the inner ear. Only in the disease state do they come loose and float around like snow in a snow globe. The Eply maneuver or variants of it do, in most cases, move the crystals from the posterior canal and back into the saccule. However, these crystals are not gone. Much like shaking a snow globe, movements over the next week weeks to months causes these crystals to find their way back into the posterior canal. Why do some people get highly recurrent BPPV? This is not well known but a good theory has to do with the number of particles which are loose. You can imagine, to extend the metaphor, that a snow globe with only a few snow flakes will take a while for them to all land in one spot - eventually it might happen by chance, but it will take time. However, if there are millions of them the chance that a single spot will be covered is higher. So to with BPPV, if you have a lot of loose crystals, you will get more recurrent episodes.
So what to do. Certainly some people have the patient come back every two weeks for a repeat maneuver. You have demonstrated that the treatment is effective but just not prolonged. You can teach the patient to do the maneuver themselves, and some patients can manage that. Also ear surgery is an option to occlude the posterior semi-circular canal. There is also a new product out which helps patients to perform their own Epley maneuver correctly. This device enables people with recurrent BPPV to treat their own symptoms at home. It is FDA cleared and requires a prescription with a diagnosis of BPPV. One nice thing for the sake of your patient is that they wouldn't require any medications, they can just repeat the maneuver at home.
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As someone who has suffered with recurrent BPPV - I have asked those same questions of anyone who would listen!! I had about 20 episodes over a two year period. They would seem to occur in clusters - i.e., once every 2 to 3 weeks or so for a few months and then stop completely for months at a time. Currently, I have not had an episode since late January and I'm hoping that continues.
Two things I have learned. One - after having many episodes (usually occurring on a weekend!), I began performing the Epley on my own and was able to successfully clear it on several occassions. However, there were many times that I just couldn't seem to get the crystals repositioned correctly. Luckily my neurotologist has an Epley chair - and that was able to clear it. My belief and the vestibular therapist's belief is that I am not always able to get my head in the right position to clear it - maybe due to the specific configuration of the canals in my ear? - but with the Epley chair, they are able to turn me completely upside down and that seems to make a difference.
Second - I finally had a phone consult with Dr. Hain in Chicago because I was tired of not having any answers. He ultimately diagnosed me with migraine. He felt the migraine was triggering the recurrent BPPV. I wasn't 100% sold on the diagnosis originally because I didn't seem to have any obvious triggers and never had any issues with migraine in the past. However, I have since had a confirmation of that diagnosis because I accidentally ate something with MSG and within 20 minutes was incredibly dizzy - I even did the Dix Hallpike because I was certain some crystals had moved. They hadn't, so it didn't trigger an episode, but it made me very dizzy. It went away in a couple of hours. So - that confirmed for me that I do have some migraine component and possibly that does trigger the BPPV episodes? I have chosen not to take a migraine preventative, but to try to manage the triggers instead, but a migraine preventative is always an option.
Sorry for the length of my response ... but I hope it was helpful. Best of luck to your patient. I feel her pain!!
ssdizzy... i realize your post was a couple of years ago, but wondered how you are doing? my symptoms are similar to yours except that i had over a year between my first bppv episode and the past 3 weeks of suffering... my initial episode this year was quite severe, but i was able to get into a dr. who performed the epley, which seemed to have worked... then a week later i was stricken again and did my own epley... i also had good resolution with that, but continue to wake up with symptoms almost every day... i am sleeping somewhat upright on 2 pillows... i sometimes feel that the bppv has switched to my other ear... what to do? i went back to the dr. yesterday (not my regular dr. as he was on vacation) and he put me on hctz (a diuretic) and said i should be fine... i'm not so confident in that, but willing to give it a try...
how did you come to realize you had a migraine component? i am open to that, but have no headaches... any information you can provide would be greatly appreciated...
Last edited by cheryltwin; 08-09-2011 at 08:55 AM.