Abstract Details

Vestibular paroxysmia consists of brief episodes of vertigo lasting a few to several seconds, several times a day with attacks unprovoked or provoked with head movements. Diagnosis is based on: at least ten attacks of spontaneous spinning or non-spinning vertigo, duration <1 minute, stereotyped phenomenology, response to treatment with carbamazepine/oxcarbazepine and not better accounted for by another diagnosis.

We present a case of recurrent progressive vertigo initially thought of as BPPV then vestibular migraine and then finally vestibular paroxysmia.

A 45-year-old female with a history of intermittent vertigo about 3-4 times previously presented for evaluation. Previous episodes of vertigo progressed from 2 weeks to 4 months. Episodes were sudden in onset of vertigo 3-4 times/day, lasting a few seconds, and triggered with upward and right gaze but not left gaze. There was associated bilateral tinnitus but absent hearing loss, auditory fullness, or migraine history. She was started on meclizine for probable BPPV but did not improve.

Brain imaging, VNG, and ENT evaluation were negative for causes of vertigo. Exam showed counterclockwise torsional and upbeating nystagmus when laying flat and turning head to the left. Abnormal head impulse test with right rotation indicated a deficient right vestibular ocular reflex implying a right peripheral vestibular lesion.

Referral to PT ordered for canalith repositioning with no improvement. A trial of carbamazepine was started, drastically decreasing episodes. On return visit, she denied any episodes of vertigo and initial nystagmus and abnormal head impulse test were resolved. Based on the history and exclusion of other peripheral causes of vertigo, patient was diagnosed with vestibular paroxysmia and continued on carbamazepine. 

This case looks into the findings of vestibular paroxysmia, its work-up, and potential other diagnoses that need to be excluded (i.e. BPPV, Meniere’s disease, Vestibular Neuritis, Labyrinthitis) as it’s an uncommon cause of peripheral vertigo.