Is Vestibular Testing Necessary? Here’s What Experts Say

In the acute setting, if vestibular neuritis is part of the differential diagnosis but not certain, then after the history and physical is done, the video head impulse test (vHIT) should be performed, she said. If it’s abnormal, no other vestibular testing is needed, she said.

In the chronic setting, Dr. Selleck believes that the vHIT is appropriate as a first test. “It’s a very low patient burden,” she said. “It’s an easy test to undergo, it’s well-tolerated by young and old patients, it’s quick, taking only about three to four minutes, it’s objective, and it examines all six semicircular canals.”

Vestibular evoked myogenic potential (VEMP) testing can be added when a physician is trying to determine the subtype of vestibular neuritis. VEMP is particularly important when it’s a case of inferior vestibular neuritis, since the test has the ability to identify the subtype. And this is useful information—it’s a more rare diagnosis that has a better prognosis, with decreased hospital stays and faster remission of spontaneous nystagmus (Otol Neurotol. 2019;40:797-805).

Case 3, Pediatric Migraine: Robert C. O’Reilly, MD, director of the Balance and Vestibular Program at Children’s Hospital of Philadelphia, discussed the case of a 5-year-old boy who had been having monthly episodes of sudden onset head tilt, nystagmus, pallor, fearfulness, and occasional emesis. He was otherwise healthy and had no balance issues between the episodes, with a normal MRI, EEG, and vestibular testing.

Dr. O’Reilly described the “migraine march” phenomenon in children, in which migraine manifests differently over time, from colic to motion sickness to paroxysmal torticollis to benign recurrent vertigo of childhood (BRVC) to vestibular migraine. The question is whether this is strictly a central process. Literature over the years has indicated a peripheral vestibulopathy, but there are lingering doubts about the quality of the studies.

In a study at Dr. O’Reilly’s center, researchers evaluated 39 children with BRVC or migraine with aura and found no evidence of peripheral vestibulopathy. “There’s really no evidence for peripheral vestibulopathy in kids with childhood migraine,” he said. “I would argue that if the picture fits with one of these classic presentations, you needn’t go on to get vestibular testing in these kids, and you can either treat them yourselves or refer them on to your neurology colleagues.”

Thomas R. Collins is a freelance medical writer based in Florida.