Vertigo pp 49-64 | Cite as

Management of the dizzy patient

  • Thomas Brandt


The prevailing good prognosis of vertigo should be emphasised, because
  • many forms of vertigo have a benign cause and are characterised by spontaneous recovery of vestibular function or central compensation of a peripheral vestibular tone imbalance;

  • most forms of vertigo can be effectively relieved by pharmacological treatment (Table 3.1), physical therapy (Table 3.2), surgery (Table 3.3), or psychotherapy (Chaps. 31 and 32).


Motion Sickness Vestibular Neuritis Head Extension Vestibular Compensation Vestibular Lesion 
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  1. Angelaki DE, Bush GA, Perachia AA (1993) Two-dimensional spatiotemporal coding of linear acceleration in vestibular nuclei neurons. J Neurosci 13: 1403–1417PubMedGoogle Scholar
  2. Averbuch-Heller L, Tusa RJ, Fuhry L, Rottach KG, Ganser GL, Heide W, Büttner U, Leigh RJ (1997) A double-blind controlled study of gabapentin and baclofen as treatment for acquired nystagmus. Ann Neurol 41: 818–825PubMedGoogle Scholar
  3. Bechterew W von (I883) Ergebnisse der Durchschneidung des N. acusticus, nebst Erörterung der Bedeutung der semicirculären Kanäle für das Körpergleichgewicht. Pflügers Arch 30:312–347Google Scholar
  4. Benecke JE (1994) Surgery for non-Menière’s vertigo. Acta Otolaryngol (Stockh) Suppl 513: 37–39Google Scholar
  5. Bergenius J, Ödkist LM (1996) Transtympanic aminoglycoside treatment of Menière’s disease. In: Baloh RM, Halmagyi GM (eds) Disorders of the vestibular system. Oxford University Press, New York, Oxford, pp 575–582Google Scholar
  6. Black FO, Shupert CL, Peterka RJ, Nashner LM (1989) Effects of unilateral loss of vestibular function on the vestibulo-ocular reflex and postural control. Ann Otol Rhinol Laryngol 98: 884–889PubMedGoogle Scholar
  7. Böhmer A, Fisch U (1993) Bilateral vestibular neurectomy for treatment of vertigo. Otolaryngol Head Neck Surg 109: 101–107PubMedGoogle Scholar
  8. Brackmann DE (1996) Surgical procedures: endolymphatic shunt, vestibular nerve section and labyrinthectomy. In: Baloh RW, Halmagyi GM (eds) Disorders of the vestibular system. Oxford University Press, Oxford, pp 551–562Google Scholar
  9. Brandt T (1993) Management of acute peripheral vestibular disorders. Eur Neurol 33: 337–340Google Scholar
  10. Brandt Th, Paulus W (1989) Postural retraining in exceptional populations. In: Wollacott M, Shumway-Cook A (eds) Posture and gait across the lifespan. University of South Carolina Press, pp 299–319Google Scholar
  11. Brandt T, Daroff RB (1980) The multisensory physiological and pathological vertigo syndromes. Ann Neurol 7: 195–203PubMedGoogle Scholar
  12. Brandt T, Dieterich M (1994) Vestibular syndromes in the roll plane: topographic diagnosis from brainstem to cortex. Ann Neurol 36: 337–347PubMedGoogle Scholar
  13. Brandt Th, Dichgans J, Wagner W (1974) Drug effectiveness on experimental optokinetic and vestibular motion sickness. Aerospace Med 45: 1291–1297PubMedGoogle Scholar
  14. Brandt Th, Krafczyk S, Malsbenden I (1981) Postural imbalance with head extension: improvement by training as a model for ataxia therapy. Ann NY Acad Sci 374: 646–649Google Scholar
  15. Brandt Th, Büchele W, Krafczyk S (1986) Training effects on experimental postural instability: a model for clinical ataxia therapy. In: Bles W, Brandt Th. (eds) Disorders in posture and gait. Elsevier, Amsterdam, pp 353–365Google Scholar
  16. Brandt T, Strupp M, Arbusow V, Dieringer N (1997) Plasticity of the vestibular system: central compensation and sensory substitution for vestibular deficits. Ann Neurol 73: 297–309Google Scholar
  17. Büchele W, Knaup H, Brandt Th (1984) Time course of training effects on balancing on one foot. Acta Otolaryngol (Stockh) Suppl 406: 140–142Google Scholar
  18. Cameron SA, Dutia MB (1997) Cellular basis of vestibular compensation: changes in intrinsic excitability of MVN neurones. NeuroReport 8: 2595–2599PubMedGoogle Scholar
  19. Carpenter DO, Horik N (1992). Neurotransmitter and peptide receptors on medial vestibular nucleus neurons. Ann NY Acad Sci 656: 668–686PubMedGoogle Scholar
  20. Courjon JH, Jeannerod M (1979) Visual substitution of labyrinthine defect. In: Granit R, Pompeiano O (eds) Progress in brain research, vol 50. Reflex control of posture and locomotion. Elsevier, Amsterdam, pp 783–792Google Scholar
  21. Courjon JH, Jeannerod M, Ossuzio I, Schmid R (1977) The role of vision in compensation of vestibulo-ocular reflex after hemilabyrinthectomy in the cat. Exp Brain Res 28: 235–248PubMedGoogle Scholar
  22. Curthoys IS, Halmagyi GM (1994) Vestibular compensation: a review of the oculomotor, neural, and clinical consequences of unilateral vestibular loss. J Vestib Res 5: 67–107Google Scholar
  23. Darlington CL, Smith PF (1992) Pre-treatment with a Cat+ channel antagonist facilitates vestibular compensation. NeuroReport 3: 143–145PubMedGoogle Scholar
  24. Darlington CL, Smith PF, Hubbard JI (1990) Guinea pig medial vestibular nucleus neurons in vitro respond to ACTH (4–10) at picomolar concentrations. Exp Brain Res 82: 637–640PubMedGoogle Scholar
  25. de Waele C, Mühlethaler M, Vidal PP (1995) Neurochemistry of the central vestibular pathways. Brain Res Rev 20: 24–46PubMedGoogle Scholar
  26. Dichgans J, Brandt T (1978) Visual-vestibular interaction: effects on self-motion perception and postural control. In: Held R, Leibowitz HW, Teuber HL (eds) Handbook of sensory physiology, vol. 8. Perception. Springer, New York, pp 755–804Google Scholar
  27. Dichgans J, Bizzi E, Morasso P, Tagliasco V (1973) Mechanisms underlying recovery of eye-head coordination following bilateral labyrinthectomy in monkeys. Exp Brain Res 18: 548–562PubMedGoogle Scholar
  28. Dieringer N (1988) Immediate saccadic substitution for deficits in dynamic vestibular reflexes of frogs with selective peripheral lesions. Prog Brain Res 76: 403–409PubMedGoogle Scholar
  29. Dieringer N (1995) “Vestibular compensation”: neural plasticity and its relations to functional recovery after labyrinthine lesions in frogs and other vertebrates. Prog Neurobiol 46:97–129PubMedGoogle Scholar
  30. Dieringer N, Precht W (1977) Modified synaptic input in chronically deafferented neurons. Nature 269: 431–433PubMedGoogle Scholar
  31. Dieringer N, Precht W (1979) Mechanisms of compensation for vestibular deficits in the frog. I. Modification of the excitatory commissural system. Exp Brain Res 36: 311–328Google Scholar
  32. Dieringer N, Künzle H, Precht W (1984) Increased projection of ascending dorsal root fibers to vestibular nuclei after hemilabyrinthectomy in the frog. Exp Brain Res 55: 574–578PubMedGoogle Scholar
  33. Dieterich M, Brandt T (1993) Thalamic infarctions: differential effects on vestibular function in the roll plane (35 patients). Neurology 43: 1732–1740PubMedGoogle Scholar
  34. Dieterich M, Straube A, Brandt T, Paulus W, Büttner U (1991) The effects of baclofen and anticholinergic drugs on upbeat and downbeat nystagmus. J Neurol Neurosurg Psychiatry 54: 627–632PubMedGoogle Scholar
  35. Dorland’s Illustrated Medical Dictionary (1994) Saunders, PhiladelphiaGoogle Scholar
  36. Ehrenberger K, Felix D (1996) Receptor pharmacological models for the therapy of labyrinthine vertigo. Acta Otolaryngol (Stockh) 116: 189–191Google Scholar
  37. Ewald JR (1892) Physiologische Untersuchungen über das Endorgan des N. octavus. Bergmann, WiesbadenGoogle Scholar
  38. Ez-Zaher L, Lacour M (1988) Effects of an extract of Ginkgo biloba on vestibular compensation in the cat. In: Claussen CF, Kirtane MV, Schlitter K (eds) Vertigo, nausea, tinnitus and hypoacusia in metabolic disorders. Elsevier, Amsterdam, pp 595–600Google Scholar
  39. Fetter M, Zee DS (1988) Recovery from unilateral labyrinthectomy in rhesus monkeys. J Neurophysiol 59: 370–393PubMedGoogle Scholar
  40. Fetter M, Zee DS, Proctor LR (1988) Effect of lack of vision and of occipital lobectomy upon recovery from unilateral labyrinthectomy in rhesus monkey. J Neurophysiol 59: 349–407Google Scholar
  41. Flohr H, Bienhold H, Abeln W, Macskovics I (1981) Concepts of vestibular compensation. In: Flohr H, Precht W (eds) Lesion-induced neuronal plasticity in sensorimotor systems. Springer, New York, pp 153–172Google Scholar
  42. Foster C, Baloh RW (1996) Drug therapy for vertigo. In: Baloh RW, Halmagyi GM (eds) Disorders of the vestibular system. Oxford University Press, Oxford, pp 541–550Google Scholar
  43. Gacek RR, Gacek MR (1996) Comparison of labyrinthectomy and vestibular neurectomy in the control of vertigo. Laryngoscope 106: 225–230PubMedGoogle Scholar
  44. Gallagher JP, Phelan KD, Shinnick-Gallagher P (1992) Modulation of excitatory transmission at the rat medial vestibular nucleus synapse. Ann NY Acad Sci 656: 630–644PubMedGoogle Scholar
  45. Gilchrist DP, Smith PF, Darlington CL (1990) ACTH(4–10) accelerates ocular motor recovery in the guinea pig following vestibular deafferentation. Neurosci Lett 118: 14–16PubMedGoogle Scholar
  46. Gonshor A, Melvill Jones G (1976) Extreme vestibulo-ocular adaptation induced by prolonged optical reversal of vision. J Physiol (Lond) 256: 381–414Google Scholar
  47. Hain TC, Fetter M, Zee DS (1987) Head-shaking nystagmus in patients with unilateral peripheral vestibular lesions. Am J Otolaryngol 8: 36–47PubMedGoogle Scholar
  48. Haines RF (1974) Effect of bed rest and exercise on body balance. J Appl Physiol 36: 323–327PubMedGoogle Scholar
  49. Halmagyi GM (1994) Vestibular insufficiency following unilateral vestibular deafferentation. Aust J Otolaryngol 1: 510–512Google Scholar
  50. Halmagyi GM, Curthoys IS (1988) A clinical sign of canal paresis. Arch Neurol 45: 737–739PubMedGoogle Scholar
  51. Halmagyi GM, Rudge P, Gresty MA (1980) Treatment of periodic alternating nystagmus. Ann Neurol 8: 609–611PubMedGoogle Scholar
  52. Halmagyi GM, Curthoys IS, Cremer PD, Henderson CJ, Todd MJ, Staples MJ, D’Cruz DM (1990) The human horizontal vestibuloocular reflex in response to high-acceleration stimulation before and after unilateral vestibular neurectomy. Exp Brain Res 81: 479–490PubMedGoogle Scholar
  53. Halmagyi GM, Curthoys IS, Todd MJ, D’Cruz DM, Cremer PD, Henderson CJ, Staples MJ (1991) Unilateral vestibular neurectomy in man causes a severe permanent horizontal vestibulo-ocular reflex deficit in response to high-acceleration ampullofugal stimulation. Acta Otolaryngol (Stockh) Suppl 481: 411–414Google Scholar
  54. Hamann KF (1988) Rehabilitation of patients with vestibular disorders. HNO 36: 305–307PubMedGoogle Scholar
  55. Herdman SJ (1996) Vestibular rehabilitation. In: Baloh RW, Halmagyi GM (eds) Disorders of the vestibular system. Oxford University Press, Oxford, pp 583–597Google Scholar
  56. Herdman SJ, Clendaniel RA, Mattox DE, Holiday M, Niparko JK (1995) Vestibular adaptation exercises and recovery: acute stage following acoustic neuroma resection. Otolaryngol Head Neck Surg 113: 71–77Google Scholar
  57. Horak FB, Jones-Rycewicz C, Black O, Shumway-Cook A (1992) Effects of vestibular rehabilitation on dizziness and imbalance. Otolaryngol Head Neck Surg 106: 175–180PubMedGoogle Scholar
  58. Igarashi M (1986) Compensation for peripheral vestibular disturbances–animal studies. In: Bles W, Brandt Th (eds) Disorders of posture and gait. Elsevier, Amsterdam, pp 337–351Google Scholar
  59. Igarashi M, Alford BR, Watanabe T, Maxian PM (1969) Role of neck proprioception for the maintenance of dynamic bodily equilibrium in the squirrel monkey. Laryngoscope 79: 1713–1727PubMedGoogle Scholar
  60. Igarashi M, Ishikawa K, Ishii M, Yamane H (1988) Physical exercise and balance compensation after total ablation of vestibular organs. Prog Brain Res 76: 395–401PubMedGoogle Scholar
  61. Ishii M, Igarashi M (1986) Effect of thyrotropin-releasing hormone on vestibular compensation in primates. Am J Otolaryngol 7: 177–180PubMedGoogle Scholar
  62. Kanayama R, Bronstein AM, Gresty MA, Brookes GB, Faldon ME, Nakamura T (1995) Perceptual studies in patients with vestibular neurectomy. Acta Otolaryngol (Stockh) Suppl 520: 408–411Google Scholar
  63. Kemink JL, Telian SA, El-Kashlan H, Langman AW (1991) Retrolabyrinthine vestibular nerve section: efficacy in disorders other than Meniere’s disease. Laryngoscope 101: 523–528PubMedGoogle Scholar
  64. Kingma H, Bonink M, Meulenbroeks A, Konijnenberg H (1997) Dose-dependent effect of betahistine on the vestibulo-ocular reflex: a double-blind placebo controlled study in patients with paroxysmal vertigo. Acta Otolaryngol (Stockh) 117: 641–646Google Scholar
  65. Krebs DE, Gill-Body KM, Riley PO, Parker SW (1993) Double-blind placebo controlled trial of rehabilitation for bilateral vestibular hypofunction: preliminary report. Otolaryngol Head Neck Surg 109: 735–741PubMedGoogle Scholar
  66. Kunkel AW, Dieringer N (1994) Morphological and electrophysiological consequences of unilateral pre-versus post-ganglionic vestibular lesions in the frog. J Comp Physiol (A) 174: 621–632Google Scholar
  67. Lacour M (1984) Réapprentissage et période postopératoire sensible dans la restauration des fonctions nerveuses. Exemple de la compensation vestibulaire et implications cliniques. Ann Oto-Laryngol (Paris) 101: 177–187Google Scholar
  68. Lacour M, Xerri C (1981) Vestibular compensation: new perspectives. In: Flohr H, Precht W (eds) Lesion-induced neuronal plasticity in sensorimotor systems. Springer, Berlin, pp 240–253Google Scholar
  69. Lacour M, Roll JR, Apaix M (1976) Modifications and development of spinal reflexes in the alert baboon ( Papio papio) following unilateral vestibular neurectomy. Brain Rev 113: 255–269Google Scholar
  70. Leigh RJ, Brandt T (1993) A reevaluation of the vestibulo-ocular reflex: new ideas of its purpose, properties, neural substrate, and disorders. Neurology 43: 1288–1295.PubMedGoogle Scholar
  71. Leigh RJ, Averbuch-Heller L, Tomsak RL, Remler BF, Yaniglos SSGoogle Scholar
  72. Dell’Osso LF (1994) Treatment of abnormal eye movements that impair vision: strategies based on current concepts of physiology and pharmacology. Ann Neurol 36: 129–141PubMedGoogle Scholar
  73. Lisberger SG, Pavelko TA (1988) Brain stem neurons in modified pathways for motor learning in the primate vestibulo-ocular reflex. Science 242: 771–773PubMedGoogle Scholar
  74. Lisberger SG, Sejnowski TJ (1992) Motor learning in a recurrent network model based on the vestibulo-ocular reflex. Nature 360: 159–161PubMedGoogle Scholar
  75. Lisberger SG, Miles FA, Zee DS (1984) Signals used to compute errors in monkey vestibulo-ocular reflex: possible role of flocculus. J Neurophysiol 52: 1140–1153PubMedGoogle Scholar
  76. Manning C, Scandale L, Manning EJ, Gengo FM (1992) Central nervous system effects of medicine and dimenhydrinate: evidence of acute tolerance to antihistamines. J Clin Pharmacol 32: 996–1002PubMedGoogle Scholar
  77. Martin J, Gilchrist DPD, Smith PF, Darlington CL (1996) Early diazepam treatment following unilateral labyrinthectomy does not impair vestibular compensation of spontaneous nystagmus in the guinea pig. J Vestib Res 6: 135–139PubMedGoogle Scholar
  78. McCabe BF, Ryu JH (1969) Experiments on vestibular compensation. Laryngoscope 79: 1728–1736PubMedGoogle Scholar
  79. Nomura Y, Okuno T, Mizuno M (1993) Treatment of vertigo using laser labyrinthectomy. Acta Otolaryngol (Stockh) 113: 261–262Google Scholar
  80. Nomura Y, Ooki S, Kukita N, Young Y-H (1995) Laser labyrinthectomy. Acta Otolaryngol (Stockh) 115: 158–161Google Scholar
  81. Petrosini L (1987) Behavioural recovery from unilateral vestibular lesion is facilitated by GM, ganglioside treatment. Behav Brain Res 23: 117–126PubMedGoogle Scholar
  82. Phelan KD, Nakamura J, Gallagher JP (1990). Histamine depolarizes rat medial vestibular nucleus neurons recorded intracellularly in vitro. Neurosci Lett 109: 287–292PubMedGoogle Scholar
  83. Pohl DV (1996) Surgical procedures for benign positional vertigo. In: Baloh RW, Halmagyi GM (eds) Disorders of the vestibular system. Oxford University Press, Oxford, pp 563–582Google Scholar
  84. Precht W, Shimazu H, Markham CH (1966) A mechanism of central compensation of vestibular function following hemilabyrinthectomy. J Neurophysiol 29: 996PubMedGoogle Scholar
  85. Raymond J, Dememes D, Nieoullon A (1988) Neurotransmitters in vestibular pathways. Prog Brain Res 76: 29–43PubMedGoogle Scholar
  86. Reason JT (1978) Motion sickness adaptation: a neural mismatch model. J R Soc Med 71: 819–829.PubMedGoogle Scholar
  87. Schaefer KP, Wilhelms G, Meyer DL (1978) Der Einfluß von Alkohol auf die zentralnervösen Ausgleichvorgänge nach Labyrinthausschaltung. Z Rechtsmed 81: 249–260PubMedGoogle Scholar
  88. Smith PF, Darlington CL (1994) Can vestibular compensation be enhanced by drug treatment? J Vestib Res 4: 169–179PubMedGoogle Scholar
  89. Smith PF, Darlington CL (1996) Recent advances in the pharmacology of the vestibulo-ocular reflex system. TINS 17: 421–427Google Scholar
  90. Snyder LH, Lawrence DM, King WM (1992) Changes in vestibuloocular reflex ( VOR) anticipate changes in vergence angle in monkey. Vision Res 32: 569–575Google Scholar
  91. Starck M, Albrecht H, Pöllman W, Straube A, Dieterich M (1997) Drug therapy for acquired pendular nystagmus in multiple sclerosis. J Neurol 244: 9–16PubMedGoogle Scholar
  92. Straka H, Dieringer N (1995) Spinal plasticity after hemilabyrinthectomy and its relation to postural recovery in the frog. J Neurophysiol 73: 1617–1631PubMedGoogle Scholar
  93. Strupp M, Arbusow V, Dieterich M, Sautier W, Brandt T (1998a) Perceptual and oculomotor effects of neck muscle vibration inGoogle Scholar
  94. vestibular neuritis. Ipsilateral somatosensory substitution of vestibular function. Brain 121: 677–685Google Scholar
  95. Strupp M, Arbusow V, Maag KP, Gall C, Brandt T (1998b) Vestibular exercises improve central vestibulo-spinal compensation after vestibular neuritis. Neurology 51: 838–844PubMedGoogle Scholar
  96. Szturm T, Ireland DJ, Lessing-Turner M (1994) Comparison of different exercise programs in the rehabilitation of patients with chronic peripheral vestibular dysfunction. J Vestib Res 6: 461–479Google Scholar
  97. Taylor HL, Henschel A, Brozek J, Keys A (1949) Effect of bed rest on cardiovascular function in work performance. J Appl Physiol 2: 223–239PubMedGoogle Scholar
  98. Thömke F, Vogt T, Hopf HC (1990) Alcohol-dependent unilateral vestibular impairment persisting after a closed head injury. J Neurol 237: 326–327PubMedGoogle Scholar
  99. Thompson RF, Spencer WA (1966) Habituation: a model phenomenon for the study of neuronal substrate behaviour. Psychol Rev 73: 16–43.PubMedGoogle Scholar
  100. Thomsen J, Bretlau P, Tos M, Johnsen NJ (1981) Placebo effect in surgery for Menière’s disease. Arch Otolaryngol 107: 271–277PubMedGoogle Scholar
  101. Tighilet B, Leonard J, Lacour M (1995) Betahistine dihydro-chloride treatment facilitates vestibular compensation in the cat. J Vestib Res 5: 53–66PubMedGoogle Scholar
  102. Timmerman H (1994) Pharmacotherapy of vertigo: any news to be expected? Acta Otolaryngol (Stockh) Suppl 513: 28–32Google Scholar
  103. Vaisrub N (1981) Summary statement to “Placebo effect for Meniere’s disease sac shunt surgery disputed”. (letter to the editor) Arch Otolaryngol 107: 773–774Google Scholar
  104. Waespe W, Cohen B, Raphan T (1985) Dynamic modification of the vestibulo-ocular reflex by the nodulus and uvula. Science 228: 199–202PubMedGoogle Scholar
  105. Xerri C, Lacour M (1980) Compensation des déficits posturaux et cinétiques après neurectomie vestibulaire unilatérale chez le chat. Acta Otolaryngol (Stockh) 90: 414–424Google Scholar
  106. Yamanaka T, Sasa M, Amano T, Miyahara H, Matsunaga T (1995) Role of glucocorticoid in vestibular compensation in relation to activation of vestibular nucleus neurons. Acta Otolaryngol Suppl (Stockh) 519: 168–172Google Scholar
  107. Zee DS (1988) The management of patients with vestibular disorders. In: Barber HO, Sharpe JA (eds) Vestibular disorders. Year Book, Chicago, pp 254–274Google Scholar

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© Springer-Verlag London 2003

Authors and Affiliations

  • Thomas Brandt
    • 1
  1. 1.Neurologische Klinik, Klinikum GroßhadernLudwig-Maximillians-UniversitätMunichGermany

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