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Hot Topics Blog

Chronic vertigo - the drugs don’t work

Rob Walker - 8 Nov, 2017

For those of you at medical school in the mid/late 1990s, the no. 1 hit song from The Verve ‘The drugs don’t work’ was no doubt an anthem belted out at many a bar or club. In parallel with the subject matter from that great song (written by Richard Ashcroft about drugs not working for his dying father, not about the lack of effect of recreational drugs as often thought - useful factoid from NB!) there are increasing areas of medicine where we need to be honest with our patients that ‘the drugs don’t work’ and look to alternative strategies. One condition where we need to change management and move away from drug treatment is chronic vertigo. 

Bob is 67 and should be reasonably fit with minimal co-morbidity, but he had a couple of episodes of BPPV a year ago and has struggled ever since. He had a couple of Epley’s manoeuvres at the time which broadly speaking sorted out his acute symptoms, but he has had persistent low grade vestibular dizziness and nausea on and off ever since. He has been on off-label betahistine for the last 6 months but it really hasn’t helped. It is ruining his life - he is getting increasingly anxious about his symptoms, the intermittent nausea is pretty unpleasant, and he is getting out less and less as he’s worried about driving incase his symptoms come on behind the wheel. It’s a 6 month wait for routine ENT outpatients and he’s getting pretty desperate, so is there anything else we can do? Thankfully YES! 

A recent article in the 'change’ section of the BMJ Sept 2017 (http://www.bmj.com/content/358/bmj.j3727?sso=) has highlighted that there is good evidence for using vestibular rehabilitation for treating chronic vertigo and that the evidence for drug treatment (including betahistine) is weak. Importantly the evidence suggests this can be safely and effectively delivered in primary care through internet based or booklet format. The rehab usually takes 6-12 weeks to complete. 

So you reassure Bob these symptoms are not a sign of a serious underlying problem and that some home based exercises can help. You direct him to the free balance retraining website (https://balance.lifeguidehealth.org/player/play/balance) and also to a very useful leaflet on helping to manage his anxiety symptoms (http://www.menieres.org.uk/files/pdfs/controlling-your-symptoms.pdf). Bob leaves a happier man, and you hum a few lines of the ‘drugs don’t work’ before your next patient… 

Rob Walker  


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Could this child have a brain tumour?

Simon Curtis - 15 Nov, 2017

General practice is hard. Endlessly rewarding yes, but hard in the sense of the numbers of patients we have to see, the complexity of the decisions we have to make and the responsibility we then have to carry for those decisions. I had a sleepless night last month, having seen Danny (name changed) a seven year old boy with some headaches in the middle of my afternoon surgery. Danny had seemed well to me but the headaches were of recent onset. Examination was as 'grossly normal' as it can be in a 7 year old. My first thought was that this was migraine and open questions to Mum & Dad revealed no other 'red flags'. But on direct questioning, yes maybe he had been a little more 'clumsy' than usual (he had inexplicably dropped a cup), his behaviour had changed and been more 'challenging' and Dad wondered if he had noticed a strange eye movement. My global impression though was that Danny was fine. I suggested cutting back screen time, an eye test, reassured, explained about migraine in childhood and suggested follow up at the end of term. After the consult Dad took Danny out while Mum shared their anxiety with me about a more serious diagnosis. I reassured her...much better it turned out than I reassured myself because it kept me awake that night. Was my natural 'optimism bias' ('common things happen commonly and things generally just resolve and work out fine') leading to a serious diagnostic error? Or had my direct questions fuelled a parental anxiety which had then transferred to me? Would this then lead to needless over investigation of a well child and create even more anxiety?  

The next day I checked the RCGP's excellent Brain Tumours in Children Toolkit based on the RCPCH guidance and the subsequent HeadSmart Campaign, and a recent evidence review in the BMJ. Excellent, clear practical guidance on when we should refer. The guidelines are clear that more than one of these symptoms of recent onset should trigger a referral. So, I picked up the phone the next day and rang Mum and Dad. 'On reflection...' I said, 'I have changed my mind'. Paediatrics were happy to see him, and Mum and Dad were happy for him to be seen. Danny was scanned and fortunately he was absolutely fine. 

Brain tumours are rare, very rare, but of devastatingly high impact and there are 500 new cases in children and young people every year. They are the most common cause of death in children and early diagnosis improves outcomes. We see large numbers of 'worried well' patients. It's our job to reassure those whilst at the same time finding the minority who have serious disease. That's a tough ask, and that's where evidence and guidelines can help us, to help inform our decision making, to make us feel less alone in the decisions we make and to reassure not just our patients but also us that we are doing the right thing. 

This is just the type of clinical conundrum and educational material that we shall be discussing on our upcoming Hot Topics Cancer for Primary Care Course . We shall be covering new guidelines, research and developments in cancer prevention, screening, diagnosis, survivorship and end of life care to help us to make better decisions.  General practice is hard, but we really hope that with the difficult, complex and emotive area of cancer this course will help to make it a little easier. 

Simon


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