________________________________________________________________________ Dizziness and Vertigo
Persistent Postural Perceptual Dizziness Cognitive-behavioral therapy, possibly combined with an SNRI such as venlafaxine or duloxetine, is strongly recommended for patients with PPPD. Patients should be encouraged to not stop taking the antidepressant too early; four to five weeks is required to assess effectiveness [15; 120]. Vestibular rehabilita-
Cervicogenic Vertigo With cervical vertigo, treatment options include manual therapy, muscle relaxant or anti-inflammatory medication, and tailored vestibular rehabilitation. With significant nerve com- pression that cannot be treated conservatively, interventional approaches remain a therapeutic option [120]. Post-Traumatic Vertigo In patients with post-traumatic vertigo, the primary diagnosis should be treated. With BPPV present, CRP plus vestibular rehabilitation is the recommended approach. For patients with brainstem or labyrinthine concussion, use vestibular rehabilitation. Vestibular suppressants may be added in cases of labyrinthine concussion [21]. DIZZINESS AND FALLS PREVENTION IN OLDER PATIENTS Dizziness and imbalance in older adults deserve specific atten- tion. Among older adults (i.e., age older than 65 years), falls are the leading cause of disability, institutionalization, and premature mortality from injury and the fifth leading cause of death. Fear of falling, also called post-fall anxiety syndrome, is a well-recognized syndrome in older adults [176; 177; 178]. In 2015, the cost of fall-related injuries in older adults in the United States was estimated to be $50 billion [179]. As such, vestibular dysfunction is critical to identify in older adults. Dizziness is highly prevalent (up to 38%) in older patients, and symptomatic dizziness or vertigo substantially increases the risk for falls [180; 181]. During 2001–2004, an estimated 35.4% of adult Americans had vestibular dysfunction requiring medical attention. The prevalence of balance impairment and vestibular dysfunction increases with age—the rate is 75% among persons older than 70 years and 85% among persons 80 years of age or older. Per- sons with vestibular disorders have an eight-fold increase in risk of falling and resultant morbidity/mortality. Uncompensated vestibular hypofunction results in postural instability, visual blurring with head movement, and subjective complaints of dizziness and/or imbalance [43].
tion can help address phobic avoidance behavior. Depersonalization and Derealization Disorder
Patients with depersonalization and derealization disorder have benefited from SSRIs, benzodiazepines, lamotrigine, opioid antagonists, and CNS stimulants, probably from targeting other mental disorders commonly associated with or precipi- tated by the disorder [81]. Mal de Débarquement Syndrome There is no established treatment for mal de débarquement syndrome, but an uncontrolled trial suggests that inducement of re-adaptation of the vestibulo-ocular reflex may result in improvement. In this approach, patients are exposed periodi- cally to a rocking that mimics the pace and direction of their perceived sway while in a full-field optokinetic stimulus [15; 172]. Other treatments under investigation include visual habituation, transcranial magnetic stimulation, and readapta- tion of the vestibulo-ocular reflex [173; 174].
Spontaneous CVS Central Vestibular and Cerebellar Syndromes
The American Academy of Neurology has made the following treatment recommendations for cerebellar syndromes associ- ated with nystagmus, vertigo, and ataxia [175]: • Episodic ataxia type 2: 4-AP 15 mg/day • Spinocerebellar ataxia or ataxia of mixed etiology: Riluzole • Spinocerebellar ataxia type 3: Valproic acid 1,200 mg/day • Spinocerebellar degeneration: Thyrotropin- releasing hormone over 14 days • Degenerative ataxias: Inpatient rehabilitation (four weeks) to improve ataxia and function, transcranial magnetic stimulation to improve cerebellar motor signs In episodic ataxia type 2, other treatment recommendations include [15; 120]: • Acetazolamide 375–1,500 mg/day • Dalfampridine sustained-release 10 mg PO once or twice per day
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