Management of Central Vestibulopathy
Vestibular rehabilitation therapy (VR) is the cornerstone of treatment for central vestibulopathy, focusing on promoting central vestibular compensation and preventing falls. 1
Diagnostic Approach
Before initiating treatment, proper diagnosis is essential:
Differentiate central from peripheral vestibulopathy using:
- HINTS examination (Head Impulse, Nystagmus, Test of Skew) - more sensitive than CT for detecting posterior circulation stroke 1
- MRI brain (without contrast) when central causes are suspected 1
- Video- or electronystagmogram to evaluate vestibular function and coordination between eyes, ears, and brain 2
Red flags requiring urgent evaluation:
- Sudden severe headache
- New neurological symptoms
- Inability to walk or stand
- Persistent vomiting
- Altered mental status 1
Treatment Algorithm
First-Line Treatment: Vestibular Rehabilitation
- Individualized vestibular rehabilitation programs are safe and effective for central vestibular dysfunction 3
- VR works through specific physical exercises that activate central neuroplastic mechanisms to achieve adaptive compensation 3
- Focus on:
- Gaze stabilization exercises
- Balance training
- Gait training
- Habituation exercises
- Fall prevention strategies 1
Pharmacological Management
- Medications should be used judiciously and typically as adjuncts to vestibular rehabilitation:
Medication Review and Deprescribing
- Review and consider discontinuing medications that may worsen dizziness:
- Sedatives
- Antihypertensives
- Muscle relaxants 1
Special Considerations
For Combined Peripheral and Central Vestibulopathy
- More complex management is required as peripheral symptoms may mask central involvement 4
- Look for signs of central vestibular dysfunction even when peripheral features are obvious 4
- Consider underlying causes:
- Acute unilateral: Consider anterior inferior cerebellar artery infarction
- Chronic unilateral: Evaluate for cerebellopontine angle tumors
- Acute bilateral: Rule out Wernicke encephalopathy
- Chronic bilateral: Consider degenerative disorders 4
For Bilateral Vestibular Hypofunction
- Patients typically present with unsteadiness when walking or standing, oscillopsia, and increased fall risk 1
- More intensive vestibular rehabilitation is needed 5
- Patient education about the condition and its long-term management is crucial 5
Follow-up and Monitoring
- Reassess patients within 1 month after initial treatment to evaluate response 1
- Use validated assessment tools to track progress:
- Activities-Specific Balance Confidence Scale
- Dizziness Handicap Inventory
- Dynamic Gait Index
- Timed Up & Go test 1
Fall Prevention
- Critical for all patients with central vestibulopathy, especially elderly patients who have a 12-fold increased risk of falls 1
- Implement home safety assessment
- Consider assistive devices for walking if needed
- Provide counseling about fall risks 1
Prognosis
- Prognosis depends on the underlying etiology and residual vestibular function
- Regular follow-up is recommended to monitor progression and response to therapy 1
- Unlike some peripheral vestibulopathies, central causes often have less complete recovery and may require long-term management 6
Pitfalls and Caveats
- Central vestibulopathy is often misdiagnosed as peripheral vertigo in emergency settings 6
- Patients diagnosed with peripheral vertigo have a higher risk of future strokes than control patients 6
- Strokes and TIAs account for approximately 25% of acute transient vestibular syndrome 6
- Combined peripheral and central vestibulopathy can be particularly challenging to diagnose as peripheral symptoms may overshadow central involvement 4