Historically, the cause of vestibular paroxysmia (VP) had been attributed to neurovascular compression of the eighth cranial despite the observation that such compression is very common in asymptomatic subjects. This paper, part of International Classification of Vestibular Disorders (ICVD) by the Bárány Society, clarifies the diagnostic criteria for the disorder based on the current best scientific evidence. The two classes are VP and Probable VP each defined by five criteria (A-E). There are explanatory notes attached to each criterion. VP is defined as follows: A) At least ten attacks of spontaneous spinning or non-spinning vertigo; B) Duration less than 1 minute; C) Stereotyped phenomenology in a particular patient; D) Response to a treatment with carbamazepine/oxcarbazepine and E) Not better accounted for by another diagnosis. Probable VP is characterised by: A) At least five attacks of spinning or non-spinning vertigo; B) Duration less than 5 minutes; C) Spontaneous occurrence or provoked by certain head movements; D) Stereotyped phenomenology in a particular patient and E) Not better accounted for by another diagnosis. The difference between the two depends on the number and duration of attacks. Additionally, response to treatment is not a requirement in Probable VP. Neurovascular compression is no longer a requirement. Stereotyped phenomenology refers to the presence of cochlear symptoms and/or symptoms of facial nerve irritation.

The paper discusses the pathophysiology, audiovestibular function test abnormalities and a wide range of differential diagnoses such as BPPV, Ménière’s disease, paroxysmal brainstem attacks, vestibular migraine, epilepsy with vestibular aura, panic attacks and vertebrobasilar TIA.

Effective treatment can take several months to years. The authors recommend a therapeutic trial of a low dose of carbamazepine (200-800mg/day) or oxcarbazepine (300-900mg/day). They conclude by discussing three areas of uncertainty of VP, namely epidemiology and clinical features, role of imaging and the lack randomised controlled trials on treatment.

Vestibular paroxysmia: diagnostic criteria.
Strupp M, Lopez-Escamez JA, Kim J-S, et al.
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Victor Osei-Lah

Bournemouth, UK.

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