Positional Vertigo: As Occurs Across All Age Groups

Introduction

Benign paroxysmal positional vertigo (BPPV) is one of the most common vestibular disorders with an estimated lifetime prevalence of 2.4% in the general adult population. Out of the 5.6 million clinic visits in the United States for dizziness per year, it is estimated that 17%–42% of patients with vertigo receive a diagnosis of BPPV. Although this disorder ranges across the lifespan, it tends to disproportionately affect older individuals aged 50–70 years and therefore has some noteworthy societal burdens. For example, it is estimated that $2000 is spent on average to diagnose BPPV, and that 86% of patients have interruption in their daily activities and lost workdays because of their vertigo symptoms. Furthermore, older patients with BPPV have a greater incidence of falls and impairments to their daily activities. These falls can result in secondary injuries including hip fractures and can lead to additional costs from hospital and nursing home admissions. Therefore, this disorder not only affects an individual’s quality of life but adversely affects society as well.

The true incidence and prevalence of BPPV are difficult to accurately estimate. Older studies have looked at the incidence of BPPV. For example, a study in Japan estimated the incidence of BPPV to be 0.01%, while a study in Minnesota estimated the incidence to be 0.06%, with a 38% increase in incidence with each decade of life. However, it is likely that these early epidemiologic studies were underestimates, as they only included patients who presented to physicians with their acute vestibular problem and did not include those who never sought medical care for their symptoms. A more recent study done in Germany looked at the estimated prevalence and incidence of BPPV in the general adult population using a cross-sectional, nationally representative survey of the general adult population in Germany. A prevalence of 2.4% overall with 3.2% in females and 1.6% in males was reported, and the 1-year incidence was calculated at 0.6%, approximately 10 times higher than earlier estimates. The 1-year prevalence was also determined as a function of age in this study. In patients aged 18–39 years, the estimated prevalence was 0.5%, whereas the 1-year prevalence for patients aged 40–59 years was 1.7%. Finally, for patients older than 60 years, the estimated prevalence was 3.4%.

Benign Paroxysmal Positional Vertigo Across the Lifespan

There are very few published reports of patients with BPPV younger than 18 years. However, one series of case reports by Giacomini described nine patients who developed BPPV after intense physical activity. Seven of these patients were younger than 36 years. There was one 16-year-old girl who developed BPPV after an intense dolphin stroke–style swimming activity. She was diagnosed with posterior semicircular canal (PSC) BPPV on the left. Our personal communication with Giacinto Asprella-Libonati, MD, noted that in his experience, approximately 1% of BPPV patients seen per year are pediatric patients aged 3–14 years. He reports that it is important to examine these children within 24–48 hours, as the diagnosis was able to be made in only 25% of patients referred to him by pediatricians. There seems to be a higher spontaneous resolution of BPPV in children, probably due to their continuous head movements when playing games. PSC-BPPV was the most common form (about 80% of patients), followed by lateral semicircular canal (LSC) BPPV (20% of patients). The patients’ BPPV was generally related to recent minor head trauma in the previous 24–48 hours (domestic injuries, sports injuries, school injuries, dental care). Interestingly, pediatric patients with recurrent BPPV usually had a family history of migraine. These patients had more episodes of typical BPPV not preceded by head injury, often with involvement of multiple canals (LSC and PSC) in subsequent episodes (Giacinto Asprella-Libonati, MD, Italy, personal communication, August 2010).

In our experience with adults aged 18–39 years, risk factors for BPPV include certain activities such as yoga, pounding activities such as running on pavement, working underneath objects such as cars, and repetitively reaching high up for things such as books. Giacomini also found that activities such as intense aerobic activity, jogging, running on the treadmill, and swimming were associated with BPPV in individuals aged 18–39 years.

Finally, in people older than 40 years, causes of BPPV include head trauma or association with other ear disorders, such as vestibular neuritis or labyrinthitis. In adults of all ages, certain movements and head positions are likely to provoke the vertigo associated with BPPV, including lying back in bed, arising quickly, looking up, bending over, or reclining for dental or hairdressing procedures.

Recent work has suggested a correlation of recurrent episodes of positional vertigo with migraine, which is why the prevalence in females may be higher, as there is a higher incidence of migraine in women. Vestibular migraine may cause episodic positional nystagmus that is difficult to differentiate from BPPV (see Chapter 11 ). The short duration of episodes (1–2 days) and frequent recurrence in otherwise healthy young patients with a history of migraine meeting International Headache Society criteria often aid in making this diagnosis. Particle repositioning maneuvers are usually not effective in vestibular migraine. The positional nystagmus seen with vertigo during vestibular migraine attacks may also appear atypical or have central features.