Positional vertigo with and without nystagmus may have either otologic or neurologic origins. The most common otologic condition we associate with transient vertigo and nystagmus lasting seconds is of course BPPV- PC or HC. In those cases, however, when it is not transient, we must consider a neurological origin.
We are often asked to evaluate patients with a prior diagnosis of M.S. whom have an onset of positional induced vertigo and nystagmus. This is to ensure that it is not merely a case of BPPV, which may be quickly remedied with a Canalith Repositioning (CRM). With the recent advances in disease-modifying agents (DMA), many M.S. patients now enjoy longer periods of remission and more normal life cycle. It is important that when there is an onset of new symptoms, they be evaluated for consideration of a period of exacerbation. The onset of positional vertigo can be especially disturbing for the M.S. patient, who when fatigued, which 80-97% are (Crayton, et al 2004) seek bed rest as a place of comfort. It is our clinical experience as well as reported in the literature (Leigh and Zee, 2001), M.S. patients may present with any form of nystagmus, horizontal, vertical or torsional with or without vertigo. Considerations may include:
Nystagmus that does not suppress with vision.
Nystagmus that occurs in more than one head position.
Documented neurological history including M.S., migraine, etc.
Nystagmus/vertigo that will not clear with CRM.
VIDEO: 49 year-old female with an 18 year history of M.S. which has been in remission, who has an onset of positional vertigo with an ageotropic nystagmus (left beating). This was accompanied over the prior month with an increased fatigue and weakness. In those cases where the clinician is unsure, it may be advisable if not medically contraindicated to treat the patient as if it is a BPPV-PC/HC (Roberts and Gans, 2008). The patient did not have a BPPV-HC or a migrainous positional vertigo (MPV). She was returned to her attending Neurologist for management, once a BPPV and MPV were ruled-out.