Timothy C. Hain, MD of Chicago Dizziness and Hearing
Page last modified: April 4, 2017
It is beginning to look as if a new treatment for migraine will hit the "streets" soon. It is called "anti-CGRP antibody" (Giamberardino et al, 2016). We expect it will be very expensive, but when covered by health insurance, potentially a game changer for refractory migraine patients.
CDH has recently begun checking new dizzy patients where there is a reasonable suspicion of cardiac disease using a rapid techology for an ECG (electrocardiogram). The thought was that dizziness is a "sorting problem", and heart disturbances are common. We are encountering "actionable" cardiac problems in roughly 10% of our patients above 60 years of age. Examples of positive findings are atrial fibrillation, AV block, bundle branch block, many ectopic ventricular beats, and bradycardia. Some of these conditions could potentially cause death or stroke. We think that this is a reasonable and useful intake process in the "dizzy clinic".
Visual vertigo is a condition where patients are intolerant of situations where there are large amounts of visual stimulation -- examples include walking through the aisles of a grocery store, difficulties with viewing scrolling computer screens, and driving problems where the speed gets above a certain threshold (often superhighway). It is sometimes diagnosed as a migraine variant (e.g. vestibular migraine), as a psychiatric condition (e.g. PPPV), as an ocular disturbance (e.g. in patients with 3rd nerve palsies or otolithic problems), and as a reorganization to loss of vestibular sensation (e.g. visual dependence).
Some progress has been made in treating this condition by the optometry profession, through manipulation of eye-wear and exercises. We have recently recruited an OD to treat this condition, Dr. Marsha Sorenson. This is going well.
Dai et al (2014) reported successful treatment with a variant of motion sickness, Mal de Debarquement, with a 5 day adaptation protocol. We sent a representative of our practice to visit Dr. Dai to learn how to do this treament, and we are offering it to MDDs patients. At this writing (4/2017), we have treated 28 patients. It works reasonably well, but it requires lots of staff and patient time. See this page regarding our progress so far.
Chicago Dizziness and Hearing has the "VHIT" test machine, which is a device that quantifies the results of "head impulses". This is a new technology to assess vestibular function. It is very good in detecting unilateral vestibular loss, such as due to tumors or vestibular neuritis. It is also modestly useful in assessing vestibular compensation - -persons who are uncompensated have "overt" saccades, and those who are compensated have "covert saccades".
We also use the VHIT to follow patients with bilateral vestibular impairment, to decide whether or not they are getting worse. It is far less stimulating that the rotatory chair, and we sometimes use it in place of VENG/R-chair in motion sensitive persons. Again it is a little tricky as people can improve on the VHIT (due to compensation) but remain unchanged on the rotatory chair (when one considers the entire vestibular response). We have also found VHIT somewhat helpful in occasional situations where a "tie breaker" is needed between ENG and rotatory chair.
Giamberardino, M. A., et al. (2016). "Anti-CGRP monoclonal antibodies in migraine: current perspectives." Intern Emerg Med 11(8): 1045-1057.