Vestibular Paroxysmia: What It Is & Why We Should Be Aware of It

In this blog, I want to share something that over the past couple of years has repeatedly come across my path being Vestibular Paroxysmia. I first remembering hearing about it from Dr. Shepard on the Talk Dizzy to Me podcast, then glanced through it on the Bárány Society website, and more recently it came up during the Advanced Vestibular Physical Therapy cohort I was fortunate to be in through the University of Pittsburgh

I’ve come to realize that, although this condition is not common, it’s certainly out there and as clinicians who work with people dealing with dizziness, we need to keep this one in the back of our minds. My approach is: if I see something once, I park it in the back of my mind and hope that I'll remember it later. See it twice, I should pay attention. By the third time? Okay, I need to understand this.

Now that it has crossed my path three times here is a summary of what I have found. I hope that you can keep it on your radar as it is only a matter of time until a patient you see has it.

What Is Vestibular Paroxysmia?

This is a rare, episodic vestibular disorder believed to be caused by compression of the vestibulocochlear, or 8th cranial nerve. It leads to very brief, spontaneous vertigo attacks—sometimes occurring dozens of times per day.

How Often Does It Occur?

While not frequently diagnosed, studies suggest it may account for up to 4% of patients in specialized dizziness clinics. With greater awareness, this number may rise as more clinicians begin to recognize its pattern.

Pathoanatomy Behind the Condition

The underlying mechanism typically involves compression of the 8th cranial nerve due to nearby blood vessels, a tumour or cyst, demyelination, trauma, and other unidentified causes near its brainstem entry. This contact can cause hyperexcitability in the nerve fibers and brief bursts of vertigo.

Vestibular Paroxysmia: Diagnostic Criteria

As per the Bárány Society consensus [2022], a diagnosis of definite cases includes:

• Ten or more brief attacks of spontaneous spinning or non-spinning vertigo lasting under one minute

• Stereotyped, recurring symptom pattern

• Positive response to carbamazepine or oxcarbazepine

• No other diagnosis better explains the symptoms

“Probable” cases may involve at least five attacks of spinning or non-spinning vertigo, lasting up to five minutes, that can come on spontaneously or with head motion.

Some may also present with aural symptoms. Symptoms and nystagmus can at times be invoked with hyperventilation. During an episode horizontal and torsional nystagmus may also be observed. Approximately 50% of patients demonstrate mild to moderate unilateral hypofunction during the attack free interval. These are, however, not a consistent findings and not part of the formal diagnostic criteria. 

Common Conditions It Can Mimic

This condition is often mistaken for:

• Benign Paroxysmal Positional Vertigo (BPPV)

• Vestibular Migraine

• Meniere’s disease

• Panic attacks

• Partial seizures or auras

Key differentiators include the frequency, brevity, and stereotyped nature of the episodes. Unlike BPPV, these are not clearly triggered by positional changes of the head.

Treatment Options for Vestibular Paroxysmia

First-line treatment involves low doses of anticonvulsant medications like carbamazepine or oxcarbazepine, which suppress abnormal nerve firing. Results can be rapid and dramatic in many cases. Surgery is rare and reserved for drug-resistant cases. While vestibular rehab may not treat the root cause, it can still support secondary balance impairments.

Prognosis and Recovery Outlook

With timely diagnosis and medication, the outlook is favorable. Some patients may taper off medication after stabilization, while others require longer-term maintenance. Misdiagnosed individuals may endure years of ineffective treatment.

Why It Belongs on Your Radar

Even if rare, missing the diagnosis can delay effective care.

Further Learning and Resources

• Talk Dizzy to Me Podcast: Vestibular Paroxysmia with Dr. Shepard

• Bárány Society Consensus Document: Vestibular Paroxysmia

• Dr. Timothy Hain’s Overview: dizziness-and-balance.com