Correct Diagnosis for the Proper Treatment of Acute Vertigo—Putting the Diagnostic Horse Before the Therapeutic Cart

Abstract

This issue of JAMA Neurology includes a methodologically rigorous systematic review and meta-analysis examining the efficacy of benzodiazepines and antihistamines in patients with acute vertigo. 1 Hunter and colleagues 1 chose an important, common clinical problem, systematically searched for relevant evidence, and then assessed the studies for both quality and risk of bias. Their primary outcome was symptom control of vertigo at 2 hours measured by a visual analog score. Secondary outcomes included symptom control at later time points. Symptom control is clearly an important patient-centric outcome; therefore, their study is relevant and timely.Hunter and colleagues 1 found that antihistamines were superior to benzodiazepines at 2 hours but not at 1 week or 1 month. Importantly, as the authors themselves acknowledge, we do not know if the statistically significant difference in self-rated symptom severity is clinically meaningful. Of the 16 studies analyzed, 9 of them gave the vestibular suppressant for "1 week to 2 months." 1 This duration of medication was in the setting of clinical trials; however, in real-life practice, patients often continue treatment with vestibular suppressants for far longer periods of time. 2,3 Of course, correct treatment of acute vertigo depends on first making a correct diagnosis-something that cannot necessarily be taken for granted. It is worth noting that Hunter et al 1 included studies of patients with acute vertigo of any cause. However, comparing symptomatic treatments for patients with acute vertigo without first determining a specific central or peripheral vestibular diagnosis ignores an enormous body of clinically relevant literature that supports disease-specific treatment. Imagine 3 emergency department (ED) patients with isolated acute vertigo or dizziness. One has typical benign paroxysmal positional vertigo (BPPV), one has vestibular neuritis, and the third has an ischemic cerebellar stroke. The study by Hunter et al 1 shows that antihistamines are more effective than benzodiazepines at controlling acute symptoms, but that is only 1 component of best management. Clearly, the ideal strategy would be to begin with a correct diagnosis, then treat accordingly in disease-specific fashion: (1) canalith repositioning maneuver for BPPV, (2) corticosteroids plus short-term (ie, 3-5 days) vestibular suppressants (Hunter and colleagues 1 would say antihistamines) and early vestibular rehabilitation for vestibular neuritis, and (3) dual antiplatelet therapy as emergent secondary prevention (or other appropriate acute stroke treatment) for the patient with posterior circulation ischemia.

“Do benzodiazepines have a future in treating acute vertigo"

“…An editorial published in JAMA Neurology concludes that antihistamines may be superior to benzodiazepines in the treatment of acute vertigo, but that proper diagnosis is superior to both. The editorial also stresses the importance of determining the specific central or peripheral differential diagnosis in patients with acute vertigo, arguing that failing to do so ignores the significance of clinically relevant literature that supports disease-specific treatment [ 18 ]. One of the most crucial objectives identified in an international survey of emergency physicians was the creation of clinical decision criteria for acute vertigo [ 19 ].…”

“…The Society for Academic Emergency Medicine began writing a clinical guideline for acute dizziness and vertigo in 2021. This guideline will give exact recommendations for diagnosing and treating first-care patients with episodic and acute vestibular disorders [ 18 ]. In a cross-sectional survey, one-fourth of 9500 acutely dizzy ED patients were misdiagnosed due to a lack of clinical criteria [ 20 ].…”