With the lack of consensus on its definition and a number of disorders with similar presentations, vestibular migraine is seldom obvious. In this guide to efficient diagnosis and effective therapeutics, otolaryngologic surgeon Caroline Schlocker, MD, walks providers through her rule-out process and clarifies criteria for vestibular migraine (as well as more common vertiginous conditions). She explains her step-up approach to care, when vestibular testing is useful, and which natural supplements can help.
yeah thank you so much for being here. It's really nice to talk to people live rather than being watched later on recording at like 1.25 X. Or 1.5 X. Which I think is the way we listen to a lot of our lectures nowadays. So yeah thank you so much for the interaction Michelle and I am going to talk about the state of their migraine today although I'm certainly happy to take other questions but since it's a group of physicians I thought kind of focusing on one topic would be pretty useful. Um I always remember like back in medical school and people were like oh you know I only have such an amount of time and I could really they have seminars on this or three day courses and I always thought that was obnoxious. But here I am they actually do have conferences and you know featured featured programs that where they talk about this all day but just sort of going over the basics and kind of addressing at least some of the E. N. T. Aspects of um dizzy with vestibular migraine being a pretty significant portion of those patients. So the objective today not from a semi perspective but just to kind of tell you how my talk is structured just introducing myself a vestibular migraine overview and then a quick differential diagnosis review. So uh this is um some contact information. So I just started that UCSF on one August as in the Navy for 16 years and in the Navy they really want a lot of general otolaryngologist but they also have residency education requirements. We do have two Navy exclusive residencies and I taught in both of them, both in Portsmouth Virginia and san Diego California. So I did one year of additional ontology training, which I took mostly to be a comprehensive otolaryngologist. It was really important to me to be an E. N. T. Who could do ear, nose and throat not shy away from the ear, which happens. So even for people who have general practices, um, I practice mostly out of redwood shores on the peninsula. It's right near san Carlos and I'm joined by four other colleagues to Ryan ologists, one other generalist and one pediatric otolaryngologist, we also have audiology services on monday and Tuesday, we're looking to expand that. But that's what we have for. And then this picture in the top right corner is actually, it's from the Usns Mercy, which is a hospital ship and in 2012 I was on it. So that's actually a picture of me on the navy dot mil website. Not that you would have any idea. I don't even think my own mother would recognize me, but I think it's cool. So you guys get to see the screenshot. So moving into vestibular migraine, which is a little less cool, but probably more important. It does affect about 2.7% of the general population and for a long time there's like a lack of consensus definition and there's still a lot of argument as to what it is doesn't exist. Some neurologists really poo poo the idea, to be quite honest. But there's a society called the Baron, a society which is an international consortium, otolaryngologist, neurologist and basic scientists who get together and talk about all things vestibular disease vertigo. And it's a great conference just F. Y. I. So they meet in Uppsala Sweden every four years and then in the intervening two they meet somewhere else. And so it's pretty it's pretty great and they have made it a priority to define sort of the clinical parameters of different conditions. So their website is actually a pretty nice resource for things such as persistent postural perceptual dis neediness. Excuse me. And vestibular pneumonitis and a few other usually more peripheral vestibular issues. So to go over the um definition of vestibular migraine. So there's vestibular migraine or definite vestibular migraine and then probable vestibular migraine, there's this they're kicking around the term of possible vestibular migraine but just in terms of trying to really stick with the evidence, which to be honest, isn't a ton right now, especially in terms of head to head treatment comparisons. They're sticking with just sort of definite and probable. So for the simpler migraine It's five episodes of moderate to severe vestibular symptoms that last five minutes to 72 hours, there's a current or previous history of migraine and the previous history can be remote, it can be you can be talking to a 50, 60 year old person and maybe if they had a migraine or two in their teens and this is sounding like vestibular migraine. I would lean heavily towards that. Um It to skip over. It can't you know, there's a better diagnosis than than that. That will be the diagnosis and it is somewhat a diagnosis of exclusion but it is it is pretty darn common. And then 50% of those vestibular episodes will have one or more migraine features. So you have the one sided pulsating modern severe pain, headache. Um Not necessarily the vertigo is an aura but you can have a sort of simultaneous migraine headache as well. Photo photo photo phobia or phone, a phobia and also visual aura and then probable vestibular migraine. Which I would say is most of my patients is the you have A. And then B. Or C. And then plus D. So I would say a lot of my patients will have By history, vestibular system symptoms that sort of aligned with vestibular migraine but maybe don't have that 50% threshold of having sort of a migraine like headache. That company is there um vertigo or dizziness symptoms, Interestingly the episode duration of the dizziness and vertigo could be highly variable. So there was a epidemiology study out of more of a neuropsychology clinic. So this is maybe not representative for a general practice but 30% of folks had it last for a few minutes 30% several hours and 30% for several days and then there are 10% where it would last seconds only but occur repeatedly and it happens with head motion, visual stimuli and change of head position, which is sort of why the differential gets a little blurry or sort of important to consider, which is why we're talking about it later in the talk. But the episode duration is the total time period of attacks. And for most of these people it tends to be kind of course symptoms or worse symptoms can be a discrete 72 hour or less period, but really it can last for minutes, two weeks. And so those folks are probably the hardest ones to kind of tease out whether or not a specific migraine or not. So a lot of the treatment mirrors what we do for a migraine headache. And so the first thing is sort of lifestyle modifications which patients appreciate because I think it restores a little bit of sort of self efficacy and actualization. Also, some people really like the idea of not necessarily jumping to medications which I sometimes have a little bit of difficulty knowing what people want because they are in the doctor's office. So sometimes it's like, oh, do you want things that, you know, doctor can offer, but sometimes they really appreciate the lifestyle discussion and it's important and something might really trigger a realization where the person's like oh my gosh that is totally it. Other times they're gonna list things like, you know, like I live a healthy lifestyle so play it by ear but it's worth mentioning. So the migraine diet is not a weight loss diet. It's not a elimination diet that you know, takes broad swaths of food groups. But this guy dr Kay shido who's out of Delaware, he's a neurologist there and really interested in vestibular migraine, his website and if you google tuxedo and migraine you'll find it um does talk about the migraine diet and just reviews different, you know, common triggering food groups that people may or may not, you know, have find a causal link to. And so it's almost like a little bit of resources slash homework for the patient to do if they're interested in thinking about diet more and giving them a resources is pretty helpful rather than spending too much time on it. Um producing stress, optimizing sleep, exercise and stretching are all very important. I tell my patients, you know, reduce your stress and optimize your sleep and then write a book about it because everyone's looking for those answers but it acknowledges that that's important. It's also sometimes hard to modify, but at least a kind of plant the seed and say, hey this is something that will help with with the migraine and again migraine as a vestibular symptom symptom Atala ji process not necessarily migraine headache. All of the two can overlap. So supplements interestingly you know practice in California down san Diego for three years and I'm in the bay area and I feel like supplements used to be more popular than than they are currently and you guys might be shaking your head or not in your head when I can't see you. And to you know, I can only speak to my practice. But it I thought people were more interested in supplements a few years ago and now they're like I'd rather do nothing or take an actual like FDA approved medication. But just to cover it um butter bird and Feverfew are two supplements that are pretty helpful. Butter burger in particular actually has like a level see evidence trial where they compared to placebo and this is several years ago. But it's butter burgers 50 to 75 mg B. I. D. I usually tell people that they're going to go to supplement route when I tell them, you know I'm a telepathic doctor, I'm an M. D. I prescribed medications. I'm not a natural path but if they do want to do it I recommend they look for a brand and it's sort independently tested by a third party and uh and also has some high quality and so butter burger, feverfew. I know amazon you know which now owns whole foods and has some pretty good links to quality manufacturers for supplements and I'm sure bad ones as well but for the good ones and they're actually doing a combination of medications with butter burger, feverfew magnesium, all those I think are quite effective. There's usually some sort of B complex of some sort in there which I'm sure patients should pee out. There's really not any great evidence for that. But the butter burger and the magnesium and feverfew gives good relief to a fair number of patients. Magnesium alone is not effective. Um there was a pretty good study in 1996 in sort of nostalgia. I have references at the end if you're interested in looking, but it actually cut the study short because when they and they were just giving magnesium but when they compare magnesium to placebo, there was no difference. Sorry about that. There's no difference in the number of migrants of people are experiencing. So sometimes people will start with mag and I don't think that's great. It's a great adjunct, not a solo therapy for medications. Um This is something that I developed in my practice over time. I'm your nose and throat surgeon. Like I like to do surgery. There is no surgery for vestibular migraines and it's such an underdiagnosed and such a prevalent disorder that it is something in my practice I became more interested in have developed a comfort with some medications. I will say I'm usually up for trying up to two and then at that point it becomes a little too complex or there might be some other central migraine process or something that quite honestly needs a neurologist I am, I refer on, but my biggest go to is probably um a triple line And that would be 10-25 mg in the evening. Since it's slightly sedating occasionally have gone up to 50 mg of a patient is doing well, but doesn't have complete control. The reason I like the amateur bowling is one, it seems to work well in a large number of patients and then to, with the slightly sedating effect, it helps with um sleep, which a lot of my patients in the past have had sleep issues that certainly don't help with the migraine. So, um, every once in while someone says they're too sedated and they wake up tired, but 25 seems to be pretty, pretty manageable for panel. All. Uh the 80 mg refers to the extended release, which I prefer to twice a day dosing and the propranolol, a beta blocker I tend to use in either people who want to avoid psychotropic medications for whatever reason, or for women who are either planning on becoming pregnant or breastfeeding or even during pregnancy, after like an appropriate discussion of risks and benefits of medications and pregnancy. I have given propranolol in pregnancy because certainly the hormonal changes are known migraine trigger for both headaches and seemingly for vestibular migraines. And so, um some people will have been, you know, non migrant workers and then pregnancy really throws them for a loop uh similar, not similarly in direct comparison or contrast. Sometimes people will have migraines, pre pregnancy and then during pregnancy, they actually have a very nice migraine free interlude, which is of course uh welcomed nor trip to lean. I'll sometimes use that as well. Vanloh vaccine is uh is a snR I that I think works well. And then verapamil is a calcium channel blocker. I have also used. I'm not the biggest fan of two pyramid I it takes time to explain a taper up to taper down to patients. And I do worry sometimes when people decide just to stop the medication, they'll just stop and not do super well. The other thing is that A lot of patients of mine who have migraines. To be honest, a lot of them have had mild traumatic brain injury or concussion in the past Topamax. Sometimes people called Topamax and they get that brain foggy feeling and if that's something they're trying to avoid what I give them a medication that has a somewhat high, 20 about 20% um, side effect of having sort of cognitive slowing and the gap repentant. Similarly, I'm just, I'm a surgeon, I don't feel like dealing with the ramp up ramp downs and hydration. So it's that's not something I tend to use. Hello, certainly it's within the armamentarium if that's something that you incorporate to your practice. Uh there was a systematic review meta analysis in 2021. And like a lot of meta analyses is kind of like there's not great trials. So it's hard to really come up with some consensus statements but they get published in good journals and so and there is something to glean from it and so they just review the several classes of medication prophylaxis and then also visit rehabilitation is useful. I think what it's best for is targeting the vestibular ocular reflex. A lot of patients with vestibular migraine and sometimes even migraine headache alone. Although I tend not to see them in my practice they will complain of with rapid head movements. Their eyes don't quite keep up. And so with that they they like to strengthen that V. O. R. And that kind of helps with that particular symptom of the eyes feeling a little slower than than their head movement. Um Just to you know highlight how amazing and cutting edge UCSF UCSF is. We are doing a pilot trial of gal cynicism eb for vestibular migraine. And so this is one of my colleagues dr Jeff Sharon. And so this is a monoclonal antibody that's injected subcutaneous lee and it you know they're seen in clinic they're evaluated. There's certainly a fair amount of inclusion criteria which you can see in that blue sidebar which for me at least is on the right side of my screen. And so talks about it and it's it is industry sponsored eli eli lilly is hoping it works but uh dr Sharon is certainly a fairly well known expert in uh I think all things vestibular and uh and if you're interested in the contact information and again this is recorded but I'm gonna stalling a little bit. So if you're trying to scribble things down you have time. His study coordinator is lovely adam. And then uh Jeff Jeff is also you know super interested in enrolling patients. And I would recommend if you have a patient that you think may fit for this trial. I would email them directly rather than placing a referral just because that way uh they want to get their study done so that the patient um will be able to be seen or at least screened faster by adam. So the vestibular migraine diagnosis, differential diagnosis. Excuse me. Uh Be PPV Meniere's disease, vestibular paroxysmal to persistent perceptual, persistent perceptual postural dizziness three P. D. And then noni. Nt ideologies. So for peripheral vestibular disorders history is key and if it's ruled in great and then if it's ruled out it's like, okay vestibular system is sort of like off the table let's think of other things and I would think for primary care doctor and I was a primary care doctor for one year on an aircraft carrier in the navy between internship and residency. So as not board certified but healthy population. I did. Okay so um so I do know that sometimes like when you have like different potential buckets where you're trying to figure out which specialists to send to. Um This is kind of a nice at least for the E. M. T. Vestibular side of things. Kind of a nice way to just look at are my patient's symptoms fitting with an E. N. T. Ideology that would require uh E. N. T. Or to learn biologist evaluation. So the big thing is time and the presence or absence of hearing loss. So you can see here in terms of the time of its seconds and there is hearing loss. And this is this may be hearing loss really only discernible on an audio graham for example like for superior semicircular canal to his since um it's a low frequency conductive hearing loss that the patient might not even know about in terms of recognizing it in their day to day life. So this might not come from the history. It might also require an audio graham as well. But semicircular coming out the distance usually the superior canal. If there's not hearing loss and it's seconds then be PPV. We'll talk more about the PPV in a second. But I will say people don't always fall into the classic be PPV history even if it is an underlying um colonia issue. Um And then sometimes the seconds like with or without hearing loss can be fluctuating compensation. So if someone's had the similar pneumonitis in the past or if they've had ear surgery in the past that kind of involved the inner ear, the body, if there is a vestibular deficit that occurs from that, the body is pretty good about compensating for it. You know, the the ecosystem is highly redundant in terms of sort of how it's wired. This is how I usually describe it to patients, but compensation is really kind of only good as a person's state of being. So if they're under a lot of stress or they're really tired, they might notice like, oh yeah, like sometimes when I'm really tired I walk, walk to the right or hit a wall. And if they have that history of a prior of a singular insult, just their fluctuating compensation could account for it minutes hours with hearing loss is Meniere's disease from any disease. The hearing loss can either be documented on audio or can just fluctuate with their episodes and come back to normal. And then a minute two hours I've sort of tucked in that a typical be PPV, which which certainly exists. And then if it stays with hearing loss is labyrinth itis, meaning that there's an inflammation of the inner ear that involves the cochlea as well as the vestibular system. And if the hearing is fine and it's just the vestibular nerd itis just the vestibule, uh vertigo aspect that's involved in the inflammation, then um you have arthritis, once you kind of think about these peripheral vestibular ideologies and once there ruled out your your sort of off the table assuming that the physical exam is normal. And so um it's kind of nice to sort of think about it because sometimes dizzy patients can really uh require a lot of emotional energy. And so if you are able to just say all right, I know you are suffering because they truly are. But then you sort of become a little bit clinical about it and just really try and fit them into these patterns and if they don't fit it's more than likely not their vestibular peripheral vestibular system. And for me as an E. N. T. I consider Is vestibular migraine or p. three d. and don't get me wrong, like I'll be on the lookout for you know, the listen out for a cardiac or neurologic or psychiatric ideology, but I think you guys have a tougher time and the broader differential that is in front of you to talk about since you guys are the usually the front line screeners. So be PPV. Um and not screener sorry. Just you see patients and really it's kind of like what is going on to stick in my lane which is E. N. T. Um be PPV is very very common. And so at a general level 5.6 million clinic visits per year in the US. And this is a pretty wide range 70 17 to 42% of patients with vertigo and this is epidemiologic data based on whether it's from a primary care clinic versus you know, sub specialist like neurologist, neurologist or neuropathologist who specializes in vertigo and dizziness, Interestingly, spontaneous recovery does happen. The thought is that the Laconia dissolve or I think a little less commonly make their way into the vestibule where they then also one dissolve and two don't cause the abnormal signaling in the semicircular canal. So about 20% will improve it one month and then 50% at three months. So if you're wondering like wait, this patient has like be PPV symptoms from by history but now is resolved in my dick hole. Pike is negative. It very well could have been that with spontaneous resolution, posterior canal just by the way it's oriented in our temporal bone is the canal where most of the Laconia fall into. In about 85% of the cases and diagnosed with six whole pike and the canal with repositioning maneuvers. The Epley and a half somersault on the right side of the screen is the Clinical Practice guidelines from the American Academy of Otolaryngology and just sort of walks through um through their sort of statements that they recommend in terms of diagnostic procedures, not ordering routine vestibular testing, um and not necessarily prescribing uh vestibular suppressants. I will say just, I mean, it took me two years into residency to do this. I realized I was getting some false negatives for my next call pike because I wasn't having the patient's head dropped 20 degrees and that can be hard in patients who have limited neck mobility because they really if you're lying someone back flat on your exam table, their head really needs to hang off at 20 degrees. And some older folks, I just can't do that. And they have these very fancy chairs that just sort of, that looked like one of those space camp Gravitt tron things where people can actually be sort of moved around to get their canals in the proper position. I don't have access to one here. I think there's a few practices in the area that have that, but just know that it may be more difficult to do the classic dicks Hall pike and Epley accurately and effectively in people who have limited cervical range of motion in the half. Somersault is something that people can do on their own and came out a little bit more recently. That might be helpful. So, um, the half Somersault is also an option so many years disease vertigo for 20 minutes to 12 hours and you have this low to medium frequency central neural hearing loss that tends to be greater than 30 decibels and at a frequency lower than 2000 hertz. This differentiates between definite and probable. So definite. Meniere's disease has this center. General hearing loss that's captured on audio graham and it can be fluctuating. It can recover. You might also see it in someone who's had Meniere's disease for a while and over time developed some sensory neural hearing loss with, with repeated attacks, probable is when the patients report this hearing fluctuation, but it's not documented on audio graham and so, and there used to be four ways that Meniere's disease was kind of divided up. And, and currently the international guidelines from the bahraini Society, basically just stick with definite and probable. You also fluctuating oral symptoms, tended this fullness and hearing and then not better accounted for by other diagnosis. And if you want to hear how interesting pathology and otolaryngology conferences are. People argue about veneers disease to the point where some people think that Meniere's disease doesn't exist and it's all migraine, I don't feel that strongly. I do think that Meniere's disease is much, much, much rarer than migraine. Um, and that includes just all the vestibular cochlear symptoms. And I would say almost all of my many years patients that I do have, almost all of them have migraine headache. It's like a co occurring uh, symptom pairing and in fact, I actually called there's like an unholy trinity which is allergic rhinitis, migraine and veneers and and kind of controlling one or both are all really help the other conditions, but your disease, I think exists. I think a lot of people find it on the internet and self diagnose. Um they're Meniere's disease and and it's just not. And so, um, I think it's something to partner with and recognize that people really feel scene and identify like with this idea of Meniere's disease being the answer to their symptoms and flat out dismissing it. I think uh leads to poor poor therapeutic relationships but kind of steering people and explaining why you do or do not think it is. Meniere's disease is very helpful, ventricular paroxysmal is funny to me. So the thought is that there's a nerve injury whether it's caused by a pressure sensation from a vascular loop, whether there's a denial in eating disorder or prior trauma. But what happens is that there's these unregulated impulses that cause these brief less than one minute recurrent spontaneous vertigo attacks. And there's just this set pattern to which it happens in patients and it's multiple times a day, it's seconds long. You may or may not see nystagmus when it occurs. But even then it's unlikely to even happen in your office if that's what they're coming in for. And it responds to Carbon Team really well. This is also pretty rare but if you're just like, gosh that sounds so weird and it it seems too short even for B. P. P. V. This is something to think about. I mean feel free to send them our way as well like this. This is you know if you have no interest in going down this rabbit hole, no sweat but I just mentioned it because um the carbon made as a team works and then it actually is almost the therapeutic intervention that makes the diagnosis. And so um that's that's something that's out there pretty rare. But you know, I always get reminded of it usually once every couple of years, that it exists because someone responds super well to carbonate supreme. I mean, I can I promise you that some people effect no, I cannot. But in terms of the pattern and really the sort of stereotyped episodes just occur with great frequency and seemingly sort of start out of nowhere and then continue to plague the patient. This is just something to consider in the differential persistent perceptual postural dizziness. So this is what used to be called a couple different names, I think when I was in training was chronic subjective dizziness. And it's basically a functional disorder where there's no structural abnormality. But the patients have continued, you usually dizziness and imbalance symptoms more than vertigo, but it is something they truly suffer from. It does exist and it's something where, especially if it can be named, sometimes that alone provides some reassurance and um patient satisfaction for knowing. And so sometimes, like, I've given especially some of the more, like scientifically minded patients, I've given them this guideline from the bahraini society. It's like 35 page pdf. And uh and they just, they feel so seen like, oh my gosh, this is me. And so what it is, is it's greater than three months of dizziness, unsteadiness or like non spinning vertigo and vertigo in this instance. And vertigo is an illusory motion motion. Uh sorry illusory sensation of motion when no motion is occurring. And often times I'll think of vertigo as rotary vertigo. But rotary vertigo is a subtype of vertigo anyway so it's prolonged symptoms and they wax and wane. People can have good days and bad days. It does not need to be continuous. There's no specific provocation factor but it's exacerbated by upright posture like sort of sitting up versus lying down, active or passive motion and then complex visual stimuli. So people will often talk about difficulties with their screens like at the grocery store with the fluorescent lights above the pattern tile looking back and forth that the different things on the shelves driving can sometimes be difficult because people have a lot of stuff going on their peripheral vision when certainly they're trying to focus on the road in front of them. The underlying cause is an acute or episodic condition that caused vertigo dizziness or imbalance. So this can be a peripheral vestibular disorder that's resolved like be PPV it can be a neurologic disorder. It can be psychiatric, it can even be um from an illness that they've had some sort of dizziness associated with the anesthetic after surgery. Or um some sort of you know vesicular pneumonitis type of picture. These symptoms cause significant distress and functional impairment. And then they're not better accounted for for other disease or disorder. So for p. three d. I think it's very common, people are very worried about it. It is not a psychiatric disorder, although there's certainly some linkages with very anxious type, a personalities that that have been seen and described in literature. Um persistent perceptible postural dizziness, excuse me, vestibular therapy is helpful for it. And so because a lot of times it happens too, is there tends to become a component. Again that is not a psychiatric disorder but causes a lot of fear. Sometimes people actually become fearful to the point of like borderline agoraphobia in terms of going out, but they develop these compensatory mechanisms often more from appropriate exception or postural uh standpoint where they are afraid of falling, which actually gives them sort of compensatory responses, almost predispose them to being knocked off balance or falling. Nor tripling 25 to 50 mg is really the only medication that's been studied so far, it doesn't have great efficacy but it's something it's something to try. So that what they've studied so far, P. Three D. Is fairly new. I think the guideline came out in 2017. Um and so and again there it's certainly been around for a lot longer. The chronic subjective dizziness uh category in the past. But I think the functional, I think we have a lot better idea of like functional diseases now and sort of how to treat people Um trying to sort of help with the symptoms, potentially medication, cognitive behavior therapy presumably could also help as well. Um, but it's tough. So I apologize. So to talk about the role of the secular testing. So in clinic, what I like to do is six tall pike. I'll be honest. I don't know is to do it. It's just like if I think the history even suggest be PPV, I'll go ahead with it. But if there's no suggestion of a B PPV type pattern, I don't necessarily do the whole pike. I'll check the extra ocular motions, make sure people can smoothly track check convergence. The head impulse test, which is where you sort of shake the head quickly back and forth and quickly have bring their head into midline all the while telling them sort of focus on something when when I wasn't wearing a mask, I would say look at my nose. I think people tend to actually lock eyes more than anything. So that also works. And if you are moving their head back and forth and quickly stop if they can stay locked on target. That's a normal head impulse test. If they if their eyes can't keep locked on the target and go off and so a corrective cicada is needed to bring it back to the target. That's an abnormal head impulse test. Gate, you know, just sort of watching, watching their gate and then also Sarah Beller screen sort of the Romberg rapidly alternating hand movements, knee down the mission holler all are helpful in my practice. I don't order a lot of formal vestibular testing as performed by the audiologist. It can certainly be helpful but there's a lot of drawbacks to it. I think people don't necessarily know about when it's time consuming. It takes about four hours out of the patient's day. Uh And it will make the patients feel poorly at some point because even with the caloric and assuming that someone has normal caloric response, they will have vertigo during the testing because that's provoked in the testing with the caloric response. The big thing for me is that it only gives glimpses into the vestibular system complexity, only specific frequencies in terms of the speed of movement. We can go very, very slow to very, very fast in normal life. But our testing only hits certain certain frequencies and certain organs within the vestibular system. And then also the specific testicular location are again not able to be tested by multiple tests. It's just like one test and they'll give you a little glimpse or peek into the function but not necessarily the whole scope. So what I'm saying is that I think the sensitivity can be low of the testing if there's not a test that directly addresses the frequency and the organ that you're thinking of. Um it requires patience and cooperation. It is difficult for patients who are actively dizzy. Like to the point where it can almost be a torture session and people and I my thought is that physical migraine is so common that it's worth treating first. And then if there's still some residual symptoms that require testing to establish a baseline or to try and figure out what is there some sort of underlying poorly compensated bilateral process or um canal process where you're trying to isolate which one it is then um then it's useful. It's also difficult, patients aren't engaged in testing so if they um maybe have a secondary gain issue where they're gonna want to maybe not participate as much or really amplify their symptoms. This is not this tested and can't really ferret that out. And then also too if the patients aren't sort of focused on the task, the testing will be inconclusive and just really quickly in terms of the hints testing or screening in more of an acute vestibular situation where you're like okay this is this testicular or is this a stroke? Right. Very important. Um And I'll be honest I usually don't see a lot of pain in the throes of an acute vestibular syndrome. So this I think would be more for an E. R. Console for me or a more urgent appointment for you all. And so hence stands for the horizontal head impulse test. Nystagmus and skew deviation. There's also one where they talk about hints with the extra s and that's standing. So let me go through the three slash four criteria. So the horizontal head impulse test, there is something called a video head impulse test where they can test all six of the canals to superior to posterior to lateral. Um For the horizontal head impulse test that you want to do clinically where you have that corrective cicada. Um If a patient can keep their eyes on the target and not need a corrective cycad, then that's not a peripheral if they always have trouble outlining it, which is why I have the table, but it's normal if you can stay on the target, which means you do not have a peripheral disorder. A peripheral disorder would have a corrective cycad present. Nystagmus, peripheral nystagmus tends to be horizontal. Yes, of course be PPV has the upward to rational but that's usually still has a horizontal component going to the side. If there's direction changing or pure vertical nystagmus, that tends to indicate a central process. And again, this is for someone acutely coming with vertigo and you're really trying and think about stroke and then skew deviation is the cover uncover test for peripheral disorder. You're gonna be able to when you cover the eye and you have your eye fixed on a target. The covered, I will be able will be conjugated, will match the uncovered I the entire time and and not move for the skew deviation when you cover an eye and there's a central process. This I usually drifts vertically either up or down that when you uncover the eyes had some skew deviation and then locks into place and then standing standing is uh people who are having a stroke tend not to be able to stand. It's a little hard because people with peripheral vestibular disorder tend to not To want to stand but but they can and so there's a really nice study in stroke and I think this was 2009 but really this is a higher sensitivity than than an M. R. I. In the 1st 24 hours for detecting hemorrhagic stroke. So um it is useful just to kind of keep this in mind. Um These are my references not complete. I mean some of this is the things I remembered our studies I looked at but um areas I think are helpful to look. The clinical practice guidelines from American Academy of Otolaryngology are quite good and they're free and accessible. I liked the review of migraine headache by the new England Journal of Medicine two years ago. The systematic review and meta analysis that really isn't very good because the underlying studies aren't that great, was in laryngoscope into 2021. The I. C. B. D. Consensus documents those are the bahraini society definitions and some treatment uh suggestions for a lot of vestibular disorders, the hints and then finally the magnesium not being a great solo treatment. So this is my team. I don't have a UCSF photo yet. Plus you get to see me in this talk. So I didn't put myself on the slide. But David Conrad's our pediatric otolaryngologist, Michael, friday. Itis worked at Kaiser for a really long time. So he's a I think he's fairly well known in the area. And um he sees our general clinic, monday, Tuesday Jose Corolla is a sinologist and school based surgeon, as is Patricia loftis. So all great people really fun to work with the great doctors and I really can't say enough nice things about them. And so here's my contact information and I really appreciate your time.