Dizziness

Diagnosis and Treatment of Benign Paroxysmal Positional Vertigo

Nathan Hinkle — Fri, 24 Apr 2026 13:24:40 +0000

Date Added:

April 24, 2026

Journal/Publication:

Journal of the American Medical Association

Publisher:

The American Medical Association

Publication Date:

April 23, 2026

URL:

Diagnosis and Treatment of Benign Paroxysmal Positional Vertigo

Type:

Meta-analyses, Reviews, and Guidelines

Format:

Article

DOI (1):

doi: 10.1001/jama.2026.1927

Keywords

benign paroxysmal positional vertigo

Vestibular Disorder

MeSH

Benign Paroxysmal Positional Vertigo* / diagnosis

Dizziness

RPR Commentary: A concise review of the diagnosis and treatment of patients with benign paroxysmal positional vertigo. James W. Mold, MD, MPH

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Benign paroxysmal positional vertigo (BPPV) is a peripheral vestibular disorder that can negatively affect quality of life and daily functioning and increase the risk of falls. BPPV is caused by dislodged otolith particles that become trapped in any of the 3 inner ear semicircular canals (anterior, posterior, or horizontal), but most commonly affects the posterior canal. Due to the posterior canal’s anatomical orientation with vertical alignment and curvature, particles in this canal tend to settle in the lowest portion and are less likely to exit with natural head movements compared with the other canals. When the head moves in the plane of the involved canal, these tiny calcium particles move in response to gravitational forces, generating fluid motion within the inner ear that displaces the cupula, the vestibular system’s main sensory structure. This temporary displacement of the cupula alters vestibular signaling, which causes involuntary eye deviation resulting in the characteristic transient nystagmus and dizziness typically described as vertigo.

Author/s:

Kevin A. Kerber, Wendy Carender, William J. Meurer

Management of Orthostatic Hypotension: A Review

Megan George — Thu, 09 Apr 2026 23:15:35 +0000

Date Added:

April 9, 2026

Journal/Publication:

JAMA

Publication Date:

April 6, 2026

URL:

Management of Orthostatic Hypotension: A Review

Type:

Meta-analyses, Reviews, and Guidelines

Format:

Article

DOI (1):

10.1001/jamainternmed.2026.0284

Keywords

PMID (1):

41941194

MeSH

hypotension

Hypotension, Orthostatic

hypertension

Dizziness

blood pressure

A review and advice about how to help patients with orthostatic hypotension. James W. Mold, MD, MPH

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Importance: Orthostatic hypotension is a common but underrecognized condition that increases with age and is associated with a lower quality of life, falls, and increased mortality. The frequent coexistence of supine hypertension and postprandial hypotension with orthostatic hypotension makes it a challenging condition to manage.

Observations: Testing for orthostatic hypotension should be done in patients with orthostatic symptoms (eg, vision changes and dizziness that occur only when upright and improve when seated or lying down), as well as asymptomatic patients in high-risk groups such as adults with frailty who are older than 70 years, individuals with neurodegenerative or autonomic disorders, and patients with unexplained falls. Patients with orthostatic hypotension should be screened for postprandial hypotension and supine hypertension to inform the treatment approach. Nonpharmacological strategies, such as medication review, increased salt and fluid intake, compression garments, and behavioral modifications, serve as fundamental approaches to treat orthostatic hypotension. Midodrine and droxidopa are the only US Food and Drug Administration-approved medications for orthostatic hypotension, but other medications (eg, fludrocortisone, atomoxetine, pyridostigmine) are used off label as part of an individualized treatment plan. Treatment targets in orthostatic hypotension are focused not on blood pressure measurements but on symptom relief and fall prevention.

Conclusions and relevance: All patients with orthostatic symptoms-along with other select patient groups-should be evaluated for orthostatic hypotension. Nonpharmacological treatments are first line, and medication decisions should be tailored based on clinical presentation and relevant comorbidities.

Author/s:

David Moloney, Ayman Youssef, Luis E. Okamoto

Tilt Table Testing

Alex Haga — Tue, 23 Apr 2024 17:41:24 +0000

Date Added:

April 23, 2024

Journal/Publication:

JAMA

Publisher:

JAMA

Publication Date:

April 11, 2024

URL:

Tilt Table Testing

Type:

Meta-analyses, Reviews, and Guidelines

Format:

Article

DOI (1):

10.1001/jama.2024.0004

Keywords

Cardiac Catheterization

PMID (1):

38602671

MeSH

hydrocortisone

Methacholine Chloride

Cardiac Catheterization

A summary and example of how to use tilt table testing in patients with syncope and various other fairly common symptoms. James W. Mold, MD, MPH

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A 43-year-old woman presented with a 1-year history of recurring symptoms of sudden onset of fatigue, palpitations, dyspnea, chest pain, lightheadedness, and nausea that were associated with standing and resolved with sitting. These symptoms began 1 month after mild COVID-19 infection. At presentation, while supine, blood pressure (BP) was 123/70 mm Hg and heart rate (HR) was 90/min; while seated, BP was 120/80 and HR was 93/min; after standing for 1 minute, BP was 124/80 and HR was 119/min. Physical examination results were normal. Oxygen saturation was 98% at rest while breathing room air. She had no oxygen desaturation during a 6-minute walk test but walked only 282 m (45% predicted). Complete blood cell count, morning cortisol, and thyrotropin blood levels were normal. Electrocardiogram (ECG), chest computed tomography, pulmonary function testing, methacholine challenge, bronchoscopy, echocardiography, and cardiac catheterization findings were normal. During tilt table testing, the patient experienced lightheadedness and nausea when moved from horizontal to the upright position. Results of the tilt table test are shown in the Table and Figure.

Author/s:

Chesire, W.P., Dudenkov, D.V., Munipalli, B.

Tilt Table Testing

Alex Haga — Tue, 23 Apr 2024 17:40:59 +0000

Date Added:

April 23, 2024

Journal/Publication:

JAMA

Publisher:

JAMA

Publication Date:

April 11, 2024

URL:

Tilt Table Testing

Type:

Meta-analyses, Reviews, and Guidelines

Format:

Article

DOI (1):

10.1001/jama.2024.0004

Keywords

Cardiac Catheterization

PMID (1):

38602671

MeSH

hydrocortisone

Methacholine Chloride

Cardiac Catheterization

A summary and example of how to use tilt table testing in patients with syncope and various other fairly common symptoms. James W. Mold, MD, MPH

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Author/s:

Chesire, W.P., Dudenkov, D.V., Munipalli, B.

Living Systematic Review on Cannabis and Other Plant-Based Treatments for Chronic Pain

Bethie Seay — Tue, 02 Nov 2021 05:00:00 +0000

Date Added:

November 2, 2021

Journal/Publication:

Agency for Healthcare Research and Quality

Publication Date:

October 27, 2021

Issue:

Volume:

Pages:

EHC036

Type:

Meta-analyses, Reviews, and Guidelines

DOI (1):

10.23970/AHRQEPCCER250

This is a summary of the evidence available to date on cannabis and other plant-based treatments for chronic pain.

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Objectives. To evaluate the evidence on benefits and harms of cannabinoids and similar plant-based compounds to treat chronic pain.

Data sources. Ovid® MEDLINE®, PsycINFO®, Embase®, the Cochrane Library, and SCOPUS® databases, reference lists of included studies, submissions received after Federal Register request were searched to July 2021.

Review methods. Using dual review, we screened search results for randomized controlled trials (RCTs) and observational studies of patients with chronic pain evaluating cannabis, kratom, and similar compounds with any comparison group and at least 1 month of treatment or followup. Dual review was used to abstract study data, assess study-level risk of bias, and rate the strength of evidence. Prioritized outcomes included pain, overall function, and adverse events. We grouped studies that assessed tetrahydrocannabinol (THC) and/or cannabidiol (CBD) based on their THC to CBD ratio and categorized them as high-THC to CBD ratio, comparable THC to CBD ratio, and low-THC to CBD ratio. We also grouped studies by whether the product was a whole-plant product (cannabis), cannabinoids extracted or purified from a whole plant, or synthetic. We conducted meta-analyses using the profile likelihood random effects model and assessed between-study heterogeneity using Cochran’s Q statistic chi square and the I2 test for inconsistency. Magnitude of benefit was categorized into no effect or small, moderate, and large effects.

Results. From 2,850 abstracts, 20 RCTs (N=1,776) and 7 observational studies (N=13,095) assessing different cannabinoids were included; none of kratom. Studies were primarily short term, and 75 percent enrolled patients with a variety of neuropathic pain. Comparators were primarily placebo or usual care. The strength of evidence (SOE) was low, unless otherwise noted. Compared with placebo, comparable THC to CBD ratio oral spray was associated with a small benefit in change in pain severity (7 RCTs, N=632, 0 to10 scale, mean difference [MD] −0.54, 95% confidence interval [CI] −0.95 to −0.19, I2=28%; SOE: moderate) and overall function (6 RCTs, N=616, 0 to 10 scale, MD −0.42, 95% CI −0.73 to −0.16, I2=24%). There was no effect on study withdrawals due to adverse events. There was a large increased risk of dizziness and sedation and a moderate increased risk of nausea (dizziness: 6 RCTs, N=866, 30% vs. 8%, relative risk [RR] 3.57, 95% CI 2.42 to 5.60, I2=0%; sedation: 6 RCTs, N=866, 22% vs. 16%, RR 5.04, 95% CI 2.10 to 11.89, I2=0%; and nausea: 6 RCTs, N=866, 13% vs. 7.5%, RR 1.79, 95% CI 1.20 to 2.78, I2=0%). Synthetic products with high-THC to CBD ratios were associated with a moderate improvement in pain severity, a moderate increase in sedation, and a large increase in nausea (pain: 6 RCTs, N=390 to 10 scale, MD −1.15, 95% CI −1.99 to −0.54, I2=39%; sedation: 3 RCTs, N=335, 19% vs. 10%, RR 1.73, 95% CI 1.03 to 4.63, I2=0%; nausea: 2 RCTs, N=302, 12% vs. 6%, RR 2.19, 95% CI 0.77 to 5.39; I²=0%). We found moderate SOE for a large increased risk of dizziness (2 RCTs, 32% vs. 11%, RR 2.74, 95% CI 1.47 to 6.86, I2=0%). Extracted whole-plant products with high-THC to CBD ratios (oral) were associated with a large increased risk of study withdrawal due to adverse events (1 RCT, 13.9% vs. 5.7%, RR 3.12, 95% CI 1.54 to 6.33) and dizziness (1 RCT, 62.2% vs. 7.5%, RR 8.34, 95% CI 4.53 to 15.34). We observed a moderate improvement in pain severity when combining all studies of high-THC to CBD ratio (8 RCTs, N=684, MD −1.25, 95% CI −2.09 to −0.71, I2=50%; SOE: moderate). Evidence on whole-plant cannabis, topical CBD, low-THC to CBD, other cannabinoids, comparisons with active products, and impact on use of opioids was insufficient to draw conclusions. Other important harms (psychosis, cannabis use disorder, and cognitive effects) were not reported.

Conclusions. Low to moderate strength evidence suggests small to moderate improvements in pain (mostly neuropathic), and moderate to large increases in common adverse events (dizziness, sedation, nausea) and study withdrawal due to adverse events with high- and comparable THC to CBD ratio extracted cannabinoids and synthetic products in short-term treatment (1 to 6 months). Evidence for whole-plant cannabis, and other comparisons, outcomes, and PBCs were unavailable or insufficient to draw conclusions. Small sample sizes, lack of evidence for moderate and long-term use and other key outcomes, such as other adverse events and impact on use of opioids during treatment, indicate that more research is needed.

Author/s:

McDonagh, M. S., Wagner, J., Ahmed, A. Y., Morasco, B., Kansagara, D., Chou, R.

HYPERVENTILATION SYNDROME: WHY IS IT REGULARLY OVERLOOKED?

Brian Desmarais — Tue, 11 Aug 2020 16:44:08 +0000

Date Added:

August 11, 2020

Journal/Publication:

The American Journal of Medicine

Publication Date:

August 9, 2020

URL:

HYPERVENTILATION SYNDROME: WHY IS IT REGULARLY OVERLOOKED?

Type:

Meta-analyses, Reviews, and Guidelines

Format:

Article

DOI (1):

https://doi.org/10.1016/j.amjmed.2020.07.006

MeSH

A short, case-based review of the diagnosis and management of hyperventilation syndrome, an extremely common cause of nonspecific “dizziness.” James W. Mold, MD, MPH

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Not available.

Opioid Treatments for Chronic Pain. Comparative Effectiveness Review No. 229

John Bayhi — Fri, 17 Apr 2020 17:45:13 +0000

Date Added:

April 17, 2020

Journal/Publication:

AHRQ Publication No. 20-EHC011

Publisher:

Agency for Healthcare Research and Quality

Publication Date:

April 16, 2020

URL:

Opioid Treatments for Chronic Pain. Comparative Effectiveness Review No. 229

Type:

Meta-analyses, Reviews, and Guidelines

Format:

Article

DOI (1):

10.23970/AHRQEPCCER229

Keywords

MeSH

opioid-related disorders

drug overdose

analgesics, non-narcotic

AHRQ evidence review of opioids for relief of chronic pain. James W. Mold, MD, MPH

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Objectives. Chronic pain is common, and opioid therapy is frequently prescribed for this condition. This report updates and expands on a prior Comparative Effectiveness Review on long-term (≥1 year) effectiveness and harms of opioid therapy for chronic pain, including evidence on shorter term (1 to 12 months) outcomes.

Data sources. A prior systematic review (searches through January 2014), electronic databases (Ovid MEDLINE®, Embase®, PsycINFO®, Cochrane CENTRAL, and Cochrane Database of Systematic Reviews through August 2019), reference lists, and clinical trials registries.

Review methods. Predefined criteria were used to select studies of patients with chronic pain prescribed opioids that addressed effectiveness or harms versus placebo, no opioid use, or nonopioid pharmacological therapies; different opioid dosing methods; or risk mitigation strategies. Effects were analyzed at short-term (1 to <6 months), intermediate-term (≥6 to <12 months), and long-term (≥12 months) followup. Studies on the accuracy of risk prediction instruments for predicting opioid use disorder or misuse were also included. Random effects meta-analysis was conducted on short-term trials of opioids versus placebo, opioids versus nonopioids, and opioids plus nonopioids versus an opioid or nonopioid alone. Magnitude of effects was classified as small, moderate, or large using predefined criteria, and strength of evidence was assessed.

Results. We included 115 randomized controlled trials (RCTs), 40 observational studies, and 7 studies of predictive accuracy; 134 were new to this update. Opioids were associated with small benefits versus placebo in short-term pain, function, and sleep quality. There was a small dose-dependent effect on pain, and effects were attenuated at longer (3 to 6 month) versus shorter (1 to 3 month) followup. Opioids were associated with increased risk of discontinuation due to adverse events, gastrointestinal adverse events, somnolence, dizziness, and pruritus versus placebo. In observational studies, opioids were associated with increased risk of an opioid abuse or dependence diagnosis, overdose, all-cause mortality, fractures, falls, and myocardial infarction versus no opioid use; there was evidence of a dose-dependent risk for all outcomes except fracture and falls.

There were no differences between opioids and nonopioid medications in pain, function, or other short-term outcomes. Opioid plus nonopioid combination therapy was associated with little improvement in pain at short-term followup versus an opioid alone. Co-prescription of benzodiazepines or gabapentinoids was associated with increased risk of overdose versus an opioid alone. No RCT evaluated intermediate- or long-term benefits of opioids versus placebo. One trial found stepped therapy starting with opioids to be associated with higher pain intensity and no difference in function or other outcomes versus stepped therapy starting with nonopioid therapy.

Limited evidence indicated no differences between long- and short-acting opioids in effectiveness, but long-acting opioids were associated with increased risk of overdose. One RCT found a taper support intervention associated with greater improvement in function but no difference in pain versus usual care.

Estimates of diagnostic accuracy for various risk prediction instruments were highly inconsistent, and there was no evidence on the effectiveness of risk mitigation strategies for improving clinical outcomes, with the exception of one study that found provision of naloxone associated with decreased emergency department visits.

Trials of patients with prescription opioid dependence found buprenorphine maintenance associated with better outcomes than buprenorphine taper and similar effects of methadone versus buprenorphine. Evidence was insufficient to evaluate benefits and harms of opioid therapy in patients at higher risk for opioid use disorder.

Conclusions. At short-term followup, for patients with chronic pain, opioids are associated with small beneficial effects versus placebo but are associated with increased risk of short-term harms and do not appear to be superior to nonopioid therapy. Evidence on intermediate-term and long-term benefits remains very limited, and additional evidence confirms an association between opioids and increased risk of serious harms that appears to be dose-dependent. Research is needed to develop accurate risk prediction instruments, determine effective risk mitigation strategies, clarify risks associated with co-prescribed medications, and identify optimal opioid tapering strategies.

Author/s:

Chou, R, Hartung, D, Turner, J, Blazina, I, Chan, B, Levander, X, McDonagh, M, Selph, S, Fu, Pappas

Subconcussive Football Hits May Leave a Telltale Signature of Brain Damage

John Bayhi — Fri, 04 Oct 2019 13:19:44 +0000

Date Added:

October 4, 2019

Journal/Publication:

JAMA

Publisher:

American Medical Association

Publication Date:

October 3, 2019

URL:

Subconcussive Football Hits May Leave a Telltale Signature of Brain Damage

Type:

Clinical Research Results

Format:

Article

DOI (1):

10.1001/jama.2019.15361

Keywords

PMID (1):

31580382

MeSH

Humans

male

football

Chronic Traumatic Encephalopathy

Diffuse Axonal Injury

White Matter

Diffusion Magnetic Resonance Imaging

Head Protective Devices

brain concussion

brain

Craniocerebral Trauma

Soccer

retrospective studies

cohort studies

Even sub-concussive head injuries can injure the brains of football players. James W. Mold, MD, MPH

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College football players in the United States endure over 1000 head hits every season. Although many don’t produce symptoms such as dizziness or blurred vision that often accompany frank concussion, these “clinically silent” hits are associated with the same type of brain damage as concussion, according to a recent Science Advances study.

Author/s:

Sancar, F