What is central vestibular dysfunction? PPPD, Vestibular Migraine, MdDS, and more!

What is central vestibular dysfunction? PPPD, Vestibular Migraine, MdDS, and more!

Dizziness can come from many sources. Therefore, one of the goals of a healthcare provider is to start to rule in or out possible causes of a patient’s symptoms of dizziness. One of the distinctions that may need to be made is if the dizziness the patient is reporting is coming from the peripheral vestibular system (the labyrinth of the inner ear, and the pathways/nerves connecting to the brainstem) or the central vestibular system (the brain and brainstem). Being able to find the vestibular system involved is key in helping the healthcare provider decide on further testing, determine the urgency of the symptoms, and develop treatment plans.

In this video, Dr. Amir Kheradmand discusses different types of central vestibular disorders and how they are treated.



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Dr. Amir Kheradmand 

Hi, I’m Dr. Amir Kheradmand with specialty in assessment of Vestibular Disorders. Today, we are going to talk about and cover some key aspects related to central vestibular dysfunction. Central vestibular dysfunction is any form of dizziness or vertigo related to brain functions that process information relayed from balance sensors inside are yours. So our ears are sensory organs that can pick up sound waves. And you’re also key to our balance by sensing head movements. This information is actually used to sense our position movement and oriented the surrounding environment for our brain. And once this vestibular information reaches the brain, it is processed along with other sensory information like visual inputs or sensory information that comes from muscles and joints. And all this information that come together and then constantly have to be updated based on sensory inputs that are available, which is an important process for being able to stand up right, walk and perform activities without losing our balance. So when we talk about peripheral vestibular dysfunction, we refer to those dysfunctions that affect vestibular sensors in the ear or dinner that carry the vestibular information to the brain. And then any dysfunction that can affect how this vestibular information is processed by the brain is called the central vestibular dysfunction. And this is a very broad range, which can include what the brain does to, for example, maintain posture or balance or coordinate eye movements or detect cell for any external motion or orient to the surrounding environment. And the vestibular system is sort of unique, because the information that comes from the vestibular system converges with other sensory inputs. And by itself vestibular system does not result in a separate or distinct sensation, like hearing or vision does. And this is actually a helpful analogy to better understand the concept of central and peripheral vestibular functions. When we use a computer mouse, the mouse is connected through a cable to the computer. And in this example, the mouse is the vestibular sensory and the ear. And the cable is the vestibular nerve and the computer is the brain. So if something goes wrong with the mouse, or the cable that connects the mouse to the computer, that would be a peripheral vestibular disorder. And anything that is related to the hardware or software problem inside the computer that can affect how mouse signals are used in different computer programs would be at Central disorder. So the same goes for the vestibular system, anything that affects the vestibular system inside the ear, or the vestibular nerve is a peripheral vestibular disorder and anything inside the brain that processes vestibular signals for different functions is considered central vestibular disorder there are three most common disorders including vestibular migraine, and a condition that is called persistent postural perceptual dizziness, which is known often by its acronym as triple E, and Malibu department syndrome, which is also often known by its acronym as MdDS. And these are complex but common disorders that involve how the stimulus information is processed along with other sensory information in the brain to serve some chief functions related to how we orient to our surrounding or how we sense our body position or motion. One of the most common disorders. Among these is vestibular migraine, which is a mix of two common problems, migraine and dizziness. When someone has vestibular migraine, they experience not only headaches, but they could also have episodes of feeling like they’re spinning, unsteady or off balance and these the dizzy spells can happen with or without the headache. And there are often other typical migraine symptoms like nausea and sensitivity to light or sound. It’s like having a headache and feeling like riding on a roller coaster at the same time. The second disorder is persistent postural perceptual dizziness or triple BD which is a disorder of like MySuper migraine and can have a frequent feeling of unsteadiness or fall sensation of motion like vestibular migraine. And both of these disorders can last for weeks, months or even longer and can make everyday activities feel very challenging because the way one can feel off balance and the constant feeling of dizziness or unsteadiness is often not related to any specific triggering these patients usually, activities can make these symptoms worse, and they become even more pronounced with head or body. Both patients with a triple PDN must have your migraine report more dizziness in busy or crowded environments. And as a key component. Anxiety can become a prominent feature in these patients and some folks may develop fear of falling or develop dizziness in public places. Triple P D may also start after a vestibular injury like for example, in patients who have or suffer from distributed neuritis, which means that that in these cases, the brain has failed to adapt or recover properly from the injury and as a result, triple PD symptoms can develop with the other disorders that are the MDTs or Malveaux development syndrome, or what is called as a dis Embarkment syndrome. There is persistent sensation of rocking, swaying or bobbing similar to the feeling of being on a boat. And this typically happens after being on a boat shape or other forms of Transportations like planes, or with sports like skiing or with long use of virtual reality headsets. The key feature is usually the constant motion sensation with moving or rocking back and forth which can persist for weeks, months or even years. So this is different from motion sickness, which usually improves when the motion stops. But MdDS symptoms usually continues even when there is no emotion and usually feels better during function. But treatment largely depends on the nature of vestibular dysfunction, and it can include a wide range of interventions from lifestyle modification, dietary adjustments, medications, vestibular physical therapy or interventions that can enhance balance functions and coordination like daily dancing, and those who are significantly impaired by their symptoms often benefit from a combined intervention with both for example medication and intense rehabilitation programs to retrain brain skills needed to regain balance functions. For some patients, identifying triggers and coming up with measures to control them can be the first line of treatment for example, dietary adjustment for migraine patients and eliminating some triggers like red wine a Cheese, artificial sweeteners, processed meat or many other common triggers can be the first step. There are also several types of medications that can be effective and use to help improve symptoms. And vestibular rehabilitation can be very beneficial to some patients, especially if there are some complications like D conditionings, or high visual dependency. Natural activities that can enhance balance and body coordination like ping pong and dancing can be very effective in some patients. But that didn’t need to be done daily for several weeks to retrain brain functions that use vestibular information. Interestingly, this is the same approach that dancers use to train their brains so that they can perform complex maneuvers that they do so an effective treatment for patients would be tapping into the same brain capacity to retrain skills needed for proper motion sensation and spatial orientation. And, as I mentioned, there are several types of medications that can be used to improve symptoms. But because of the complex nature of central dysfunction, it’s hard to have a common recipe for all patients. And each medication can have different effect on symptoms in different patients. And that’s why it’s important to be able to choose the right medication depending on the main features of the symptoms, each individual patient. So we have to keep in mind that medications are often not effected just by themselves, and they have to use us in combination with other treatment strategies. It’s like when there is a car engine problem, we can just fill up the tank and fix the problem, it’s important to properly address the engine problem and the same goes for the effective medications. They’re effective to provide the needed boost for the patients but in conjunction with other treatment strategies. There could be different providers with different specialties involved in the care of patients with a central vestibular dysfunction neurologist that are specialized in five movements. And Mr. Graham disorders for EMT physicians who are also specialized in evaluation of vestibular function could help diagnose these patients. And physical therapists who are specialized in balance and vestibular function are also very helpful assessments and performing physical therapy treatment treatments that needed for recovery these patients. Well, the first and most important step is more research to better understand and mechanisms involving a chronic daily symptoms in these patients. Most of these diagnoses that fall under the category of a central vestibular dysfunction are relatively new diagnosis, and we don’t know much about them compared to other vestibular dysfunctions. But in recent years, the research has really made progress in this field in understanding some aspects of symptoms in these patients and how processing and integration of vestibular information can be effective in central vestibular disorders. And what brain regions could be involved as a result of these dysfunctions. Once we better understand the brain networks involved in these disorders, then we can have novel treatments to directly target these networks or have specific interventions based on the level of dysfunction in every patients. And there are some promising tools for treatment that are available and we’re now using a research like transcranial magnetic stimulation, which allows modifying and enhancing brain In connections to the effect of magnetic pulses that can stimulate nerve cells in the brain. With TMS we can stimulate brain activity and through that have some effects on symptoms in patients. So hopefully a tool like that can be used in the future for treatment of some of the central vestibular dysfunctions. I hope that was helpful. Answer any questions that you might have about central vestibular dysfunctions.