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    of 3
    Correct Diagnosis for the Proper Treatment of Acute Vertigo— Putting the Diagnostic Horse Before the Therapeutic Cart Jonathan A alow, MD; Yun Agrawal, MD, MPH, Davi. Mewean Toker, MO, PAD ‘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." Hunter and colleagues’ a chose an important, com- atin sities mon clinical problem, sys- tematically searched for rel- evant evidence, and then assessed the studies for both 4uality and risk of bias. Their primary outcome was symp- tom control of vertigo at 2hours measured by a visual ana- Jog score. Secondary outcomes included symptom control at later time points. Symptom control is clearly an impor- tant patient-centrie outcome; therefore, their study is rel- evant and timely. -Hunterand colleagues? foune that antihistamines were su- perior to benzodiazepines at 2 hours but not at 1 week or 1 month. Importantly as the authors themselves acknow!- edge, we do not know ifthe statistically significant differ- ence in self-rated symptom severity is clinically meaningful. Of the 16 studies analyzed, 9 of them gave the vestibular sup- pressant for“1 week to 2 months”: This duration of medica tion was in the setting of clinical trials; however, in real-life practice, patients often continue treatment with vestibular sup- pressants for fa longer periods of time.” Of course, correct treatment of acute vertigo depends on first making a comect diagnosis~something that cannot nec- e-sarilybe taken or granted. tis worth noting that Hunter etal” included studies of patients with acute vertigo of any cause. However, comparing symptomatic treatments for patients with acute vertigo without first determiningaspecificcentral or pe- ripheral vestibular diagnosisignores an enormousbody of din: cally relevant literature that supports disease-specific teat- ‘ment. Imagine 3 emergency department (ED) patients with isolated acute vertigo or dizziness. One has typical benign par- coxysmal positional vertigo (BPPV), one has vestibular new- tis, and the third hasan ischemic cerebellar stroke. The study by Hunter etal showsthat antihistamines are more effective than benzodiazepines at controlling acute symptoms, butthat is only 1 component of best management. Clearly, the ideal strategy would be tobegin witha correct diagnosis, then reat accordingly in disease-specific fashion: ) canalithrepostion- ‘ng maneuver for BPP, (2) corticosteroidsplusshort-term Ge, 3.5 days) vestibular suppressants (Hunter and colleagues! ‘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) forthe patient with posterior circulation In particular, canalith repositioning for BPPV is among the most effective treatments in modern medicine, with estimates of the number needed to treat in some studies as low as 1.4 treatments applied to achieve 1 patient who directly benefts.* Hunter et al! included 3 studies among patients with BPPV that compared the Epley maneuver alone with the maneuver in combination with antihista- ‘mines. In their subgroup analysis, antihistamines showed a trend toward greater effectiveness among patients without BPPV than among those with BPPY, which is consistent with the principle that specific treatment of BPPV works better than symptomatic therapies, whether alone or in combina- tion with a canalith repositioning maneuver. ‘Adopting a symptomatic medication management approach ftom the outset is also nota risk-free proposition, even for patients ultimately confirmed to have peripheral vestibular disorders. BPPV not treated within 24 hours has more than double the recurrence risk (46% vs 20% P = .002)' and is associated with 6.5-fold greater odds of falls Used longer term, antihistamine treatment, meclizine being the most common in the US, exposes the patient to Fisks from adverse effects, complications, and a protracted diagnostic journey. Primary care physicians often treat ver- tigo with antihistamines for long periods of time (some- times years or even decades).” Therefore, patients may get “stuck” taking vestibular suppressants after ED discharge and be given instructions to follow up in primary care.* Antihistamines used for vertigo cross the blood-brain bar- rier, and their use is associated with falls and injury, espe- cially among older adults.’ The American Geriatric Society has a strong recommendation against meclizine use in older individuals, owing to its anticholinergic adverse effects.* In those with vestibular neuritis, vestibular suppressant use beyond a few days may diminish or delay central com- pensation, which is an important mechanism for clinical improvement.” Finally the “treat frst, ask questions later” approach for some patients can mark the beginning of an extended diagnostic journey, sometimes lasting months or even years before disease-specific treatment is applied.2? Optimized treatment of acute vertigo depends on prompt, accurate diagnosis; therefore, what do we know about cur- rent diagnosticperformance in these patients? Most ofthe data on frontline clinicians comes from the ED. We know that apre- senting symptom of dizziness increases the odds of stroke mis- diagnosis 14-fold.%® We know that computed tomography falsely reassures clinicians! We know that pesitional maneu- vers to diagnose BPPV are vastly underused or incorrectly interpreted.” JAMANeurlogy Septenber2022. Volume 73, Number (© 2022 American Medical Association. All rights reserved. Opinion titra Unfortunately, neurologists are also not immune to mis diagnosing patients with vestibular symptoms. In a German ‘study of patients with dizziness examined by a neurologist in {the ED (the neurologist routinely examined patients with and ‘without Frenzel lenses and used head impulse, nystagmus, test ‘of skew [HINTS] testing), 124 pationts were either hospital- ized or had a second ED visit within 4 weeks. The initial di ‘agnosis was changed in nearly one-half of cases."* In 10% of patients (7 of 67) with central nervous system causes, an int tal benign diagnosis was changed to a serious one on re- evaluation. Some of the reasons why misdiagnosis of vertigoand diz ines is so common include overteliance on symptom type (eg, vertigo vs dizziness vs presyncope vs unsteadiness) to ‘guide the diagnostic process; underuse and misuse of timing ‘and triggers for vestibular symptoms to formulate a differen. tial diagnosis; underuse, misuse, and misconceptions linked tothe ocular motor examination; overreliance on age and tra

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