EDITOR'S NOTE: The following is the author's reply to the above letter regarding the article "Migraine in Balance Patients" from the November/December 2008 ADVANCE for Audiolgists.
Thanks for your comments. I quoted Dr. Hain word for word, so I don't believe a published correction is necessary.
In Dr. Neuhauser's review, he cites Dr. Bronstein as the source for the statement "...it is not only the most frequent cause of recurrent vertigo..." but, in the article cited, Dr. Bronstein actually said, "In turn, benign paroxysmal positional vertigo (BPPV) is one of the most frequent causes of vertigo." (emphasis added). The full text of the Bronstein article is found here: www.co-neurology.com/pt/re/coneuro/fulltext.00019052-200302000-00001.htm.
On the face of it, it simply appears that Dr. Hain and Dr. Neuhauser simply disagree about which is more common. The following points may help to clarify this apparent disagreement.
1. In his quote, Dr. Neuhauser specified recurrent vertigo. Dr. Hain did not, so his count may well include acute and chronic cases.
2. Per Dr. Shepard: "It is more common to have BPPV as part of a more encompassing diagnosis then as a pure entity by itself," (www.audiologyonline.com/interview/interview_detail.asp?interview_id=377). At your own facility, Dr. Herdman has examples (in the 3rd edition of Vestibular Rehabilitation) of BPPV in association with other disease (pages 257, 264, 377). In another article (www.ncbi.nlm.nih.gov/pubmed/17215687), Dr. Neuhauser himself noted that there may be a relationship between BPPV and migraine. This has been our clinical experience as well. In the case where BPPV is secondary to an underlying disorder such as vestibular neuritis, Meniere's or even migraine (www.ncbi.nlm.nih.gov/pubmed/10778892 and www.ncbi.nlm.nih.gov/pubmed/15724736), how are the cases to be counted when investigating how common each disorder is in the clinical population? If you count both pure BPPV and secondary BPPV together, you'll get a much higher number than if only pure BPPV (with no other vestibular disorder) cases are counted. At our facility, we count secondary BPPV separately from pure BPPV, since the presumption is that the BPPV condition is part of the underlying disease process.
3. A corollary issue to #2 is the question, "How thorough was the investigation that identified BPPV and (presumably) ruled out other disease processes?" If the diagnostic workup stopped as soon as BPPV was identified, secondary cases could be lumped in with pure cases. Dr. Hain has the availability of full diagnostic vestibular testing at his facility, as do we at our facility. The epidemiological approach that Dr. Neuhauser cites relied upon "interviews and not on positioning manoeuvres."
I think we can agree that both disorders are extremely common. We may also agree that the two often co-travel. In his review, Dr. Neuhauser said, "The epidemiology of vertigo and vestibular disorders, however, is still an underdeveloped field." We may simply have to wait until the field is further developed before we have an order of prevalence that all agree upon.
Thomas E. Boismier, MPH
Director of ENT|Balance
a division of Ear, Nose and Throat Associates PC
Fort Wayne, IN