Ear-related balance disorders: evidence and resources

In a blog for people with ear-related balance disorders and those supporting them, Sarah Chapman and Selena Ryan-Vig from Cochrane UK share the latest Cochrane evidence and some useful resources, introduced by Professor Martin Burton. 

Featured image: ‘Spinning Down’ by Catherine Duggan. With permission via Ménière’s Society.

In this blog, we include information about the following:

There can be few physicians so dedicated to their art that they do not experience a slight decline in spirits when they learn that their patient’s complaint is giddiness.”

In this way, a distinguished neurologist introduced a chapter on giddiness in a much-used textbook of neurology. Such a reaction is due mainly because it can be so difficult to diagnose some balance disorders, and difficult to treat them. The physicians are frustrated not to be able to help their patients more easily. But dizziness or giddiness is common, and sometimes the cause is identifiable and sometimes the cause lies in the patient’s ear or ears.  A number of Cochrane reviews looked at some of these. – Professor Martin Burton.


Vestibular migraine

Vestibular migraine is a type of migraine that comes with attacks of vertigo or dizziness. Other symptoms of migraine often go with it, such as headache, sensitivity to light/noise, nausea/vomiting and visual changes.

A team from Cochrane has looked for the best available evidence on medication and on other ways to prevent vestibular migraine, and on medication to treat it, publishing three new Cochrane Reviews in April 2023. These have all highlighted a lack of reliable evidence and this is something to be aware of when making choices about treatments.

Preventing vestibular migraine

Their review Pharmacological interventions for prophylaxis of vestibular migraine shows there is very little evidence on the effects of medicines for preventing vestibular migraine, so it is unclear whether they are helpful and whether they are likely to have unwanted effects.

There is also uncertainty about the potential benefits and harms of non-drug approaches to preventing vestibular migraine, such as changes to diet or lifestyle, as shown by the Cochrane Review Non‐pharmacological interventions for prophylaxis of vestibular migraine.

Treating vestibular migraine

There’s also an evidence gap on Pharmacological interventions for acute attacks of vestibular migraine, and it’s not clear whether any medications are effective for treating vestibular migraine. While there was little information available on harms of treatment for this review, the use of triptans for other conditions (such as headache migraine) is known to have some unwanted effects.

Experiencing vestibular migraine

Writer Lydia Ruffles has given a powerful account of her experiences of vestibular migraine in her blog for Wellcome – Migraine, creativity and me.

cogs and swords in a head
‘Just Another Day’ by Therese Guy. With permission via Ménière’s Society.


Persistent postural perceptual dizziness (PPPD)

Persistent postural‐perceptual dizziness (PPPD) is a chronic balance disorder, characterised by subjective unsteadiness or dizziness that is worse on standing and with visual stimulation (for example, from complicated patterns or busy moving images).  It was only recently defined and not much is known about how best to treat it. Two Cochrane Reviews, published in March 2023, have looked for evidence on medication and on other treatments for PPPD.

Medication to treat PPPD

Medication used to treat PPPD includes drugs known as ‘selective serotonin reuptake inhibitors’ (SSRIs) and ‘serotonin and norepinephrine reuptake inhibitors’ (SNRIs). The authors of the Cochrane Review Pharmacological interventions for persistent postural‐perceptual dizziness (PPPD) looked for evidence on the effects of these but found NO studies that could be included. So we don’t know whether they are helpful or harmful for the treatment of PPPD.

Alternatives to medication for PPPD

There was just one very small study to include in the Cochrane Review on Non‐pharmacological interventions for persistent postural‐perceptual dizziness (PPPD), on transcranial direct current stimulation, and no conclusions can be drawn from it. So we don’t know whether any non‐drug treatments may be helpful for the treatment of PPPD or whether they may have any potential harms.

person drowning in stormy water
‘All at Sea’ by Lorraine Brookes. With permission via Ménière’s Society.


Meniere’s disease

Cochrane has recently published six reviews on treatments for Meniere’s disease. Unfortunately, the reviews highlight uncertainty about the benefits and harms of drug treatments (taken by mouth and put into the ear), positive pressure therapy, lifestyle and dietary changes, and surgery. You can read more in our blog Menière’s disease: experience, evidence gaps & treatment choices. As well as looking at the evidence on treatments, the blog includes one person’s experiences of living with Menière’s and making choices about treatments, and reflections from two of the review authors.

Take-home points: Menière's disease is a long-term condition affecting the inner ear. It is characterised by episodes of vertigo accompanied by tinnitus and hearing loss. Treatments aim to control symptoms and prevent deterioration of hearing and balance. Cochrane evidence on drug treatments (taken by mouth and put into the ear), positive pressure therapy, lifestyle and dietary changes, and surgery all highlight uncertainty about the benefits and harms of these treatments for people with Menière's. When making choices about treatments for Menière's, it’s important to know that evidence about the beneficial effects of treatment is lacking, and to base those choices on other factors, including personal preferences and priorities and the possible harms of treatment (although these too may be uncertain). Tim shares his experiences of living with Menière's, including his reasons for trying the treatment offered despite the lack of evidence.


Unilateral peripheral vestibular dysfunction

Unilateral peripheral vestibular dysfunction (UPVD) can happen because of disease, trauma or after surgery. It is characterised by dizziness, visual or gaze disturbances and problems with balance. It is managed with medication, physical manoeuvres and exercise regimes, the latter known collectively as vestibular rehabilitation.

The vestibular system includes the parts of the inner ear and brain that help process sensory information involved in controlling balance. Vestibular rehabilitation may be offered to people with any of a range of conditions characterised by unilateral peripheral vestibular dysfunction.

The authors of the Cochrane Review Vestibular rehabilitation for unilateral peripheral vestibular dysfunction (published January 2015) explain that “Components of vestibular rehabilitation may involve learning to bring on the symptoms to ‘desensitise’ the vestibular system, learning to coordinate eye and head movements, improving balance and walking skills, and learning about the condition and how to cope or become more active.”

The review authors conclude that “there is moderate to strong evidence that vestibular rehabilitation is a safe, effective management for unilateral peripheral vestibular dysfunction, based on a number of high‐quality randomised controlled trials”.

They also found that vestibular rehabilitation probably resolves symptoms and improves functioning in the medium term. But for people with benign paroxysmal positional vertigo (BPPV), the evidence suggests that physical (repositioning) manoeuvres are more effective in the short term than exercise‐based vestibular rehabilitation; although a combination of the two is effective for longer‐term functional recovery.


Motion sickness (travel sickness)

Also known as travel sickness, motion sickness is common. In a short blog, GP Robert Walton looks at the Cochrane evidence on treatments: Treatments to prevent travel sickness: a quick look.

Take-home points: Effective preventative treatments are available for travel sickness The choice is between hyoscine and older ‘first generation’ antihistamines New Cochrane evidence shows that some antihistamines are likely to reduce the risk of travel sickness in adults. They may cause drowsiness

More information and support

‘Dizziness and Me’ artwork

Thank you to Lorraine Brookes, Catherine Duggan, Therese Guy and the Ménière’s Society for permission to use their artwork. Do visit the ‘Dizziness and Me’ collection to see more, and to submit your own artwork about your experiences of chronic dizziness.

References (pdf)

Join in the conversation with @CochraneUK  @SarahChapman30 or leave a comment on the blog.

Please note, we cannot give specific medical advice. We do not publish comments that link to individual pages requesting donations or to commercial sites, or appear to endorse commercial products. We welcome diverse views and encourage discussion. However, we ask that comments are respectful. We reserve the right to not publish any we consider offensive. Cochrane UK does not fact check – or endorse – readers’ comments, including any treatments mentioned.

Sarah Chapman and Selena Ryan-Vig have nothing to disclose.

Ear-related balance disorders: evidence and resources by Sarah Chapman and Selena Ryan-Vig

is licensed under a Creative Commons Attribution-NoDerivatives 4.0 International

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