No history of anxiety and depression meds No hearing loss history Loud sound se kaafi problem hai jaise car ka darwaja band hone ki aawaj se irritate hota hai History of spinning Light band hone ke baad chakkar aate hai Karwat change karte waqt chakkar induce ho rhw hai Patient ko aisa lagta hai jaise aaspaas ki cheezein ghum rhi ho Allergy with Strong fragrance pehle mild fragrance jaise cucumber ya muskmelon ki smell se sar dard hota hai History of migraine: more tha 10 or 15 years
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Now I have sufficient information to provide a comprehensive VNG interpretation and clinical analysis. Let me synthesize all the data.
VNG Report Analysis — Mala Rajodia, 43F | 22-Apr-2026
Clinical Summary (from history provided)
| Feature | Detail |
|---|---|
| Migraine history | >10–15 years |
| Vertigo character | Rotational (objects spinning around patient) |
| Triggers | Position change (karwat/rolling over), lights turning off |
| Sound sensitivity | Loud sounds irritating (car door slam) — hyperacusis/phonophobia |
| Smell sensitivity | Even mild fragrances (cucumber, muskmelon) trigger headache |
| No hearing loss, no anxiety/depression meds |
VNG Test-by-Test Interpretation
1. Saccades
| Parameter | Finding | Interpretation |
|---|---|---|
| Velocity (Horiz 0.3 Hz) | RE 516 °/s, LE 528 °/s | Normal range |
| Precision (all trials) | 35–64 | Reduced (normal >70–80%) — hypometric saccades |
| Latency | 192–316 ms | Borderline prolonged (normal <200 ms ideally) |
| Vertical saccades | Similar reduced precision | Bilateral |
Interpretation: Bilateral saccadic hypometria with mildly prolonged latency. This pattern — where precision is consistently below normal bilaterally in both horizontal and vertical planes — points toward a central/cerebellar or vestibulo-cerebellar pathway dysfunction, rather than a pure peripheral lesion. Isolated BPPV does not affect saccades.
2. Smooth Pursuit
| Frequency | Horizontal Gain | Vertical Gain |
|---|---|---|
| 0.2 Hz | 0.53–0.78 | 0.52–0.56 |
| 0.4 Hz | 0.11–0.23 | 0.26–0.44 |
| 0.6 Hz | 0.08–0.15 | 0.22–0.43 |
Interpretation: Smooth pursuit gain is severely reduced horizontally at higher frequencies (0.4 and 0.6 Hz). Normal gain is ≥0.7–0.8 at these frequencies. Vertical pursuit is mildly reduced. This pattern of frequency-dependent smooth pursuit breakdown is characteristic of:
- Vestibular migraine (most common in this demographic with this history)
- Cerebellar dysfunction
- Central vestibular disorders
Pure peripheral disorders (BPPV, vestibular neuritis) do not significantly impair smooth pursuit.
3. Optokinetic Testing (OKN)
| Direction | Gain | Comment |
|---|---|---|
| Horizontal 10°–20° | 0.70–0.94 | Normal |
| Horizontal 40°–60° | 0.39–0.66 | Mildly reduced with increasing velocity |
| Vertical (Top→Bottom, Bottom→Top) | 0.07–0.20 at 20°–60° | Severely reduced |
Critical finding: Vertical OKN gain is severely impaired (0.07–0.20; normal ≥0.70), while horizontal OKN is relatively preserved at lower speeds. Asymmetric vertical OKN suppression is a central sign, pointing strongly to a brainstem or cerebellar vestibular pathway abnormality. The fast phase direction deviations recorded (56–69° for top-to-bottom, 254–257° for bottom-to-top) also suggest direction-specific asymmetry.
4. Spontaneous Nystagmus (Light and Dark)
No spontaneous nystagmus recorded in either condition (all values dash/absent).
This effectively rules out active unilateral peripheral vestibular loss (which would show nystagmus in darkness). It also argues against active Menière's disease during the testing session.
5. Head Shake / Hyperventilation Nystagmus
No nystagmus provoked — negative head-shake test, negative hyperventilation-induced nystagmus.
6. Gaze Testing
No gaze-evoked nystagmus in any direction (center, left, right, up, down — both with and without fixation).
This rules out significant gaze-holding failure (e.g., Alexander's law nystagmus) at rest.
7. Dix-Hallpike Testing — KEY FINDING
| Position | Finding |
|---|---|
| Right DH (all positions) | No nystagmus — all values negative |
| Left DH — Sit Head Left (first recording) | Vertical RE: SPV 5.77 °/s, amplitude 4.96°, frequency 0.59 Hz |
| Left DH — Sit Head Left (return) | Horizontal RE: SPV 6.44 °/s, amp 5.37°; Vertical RE: SPV 5.50, amp 4.49°, freq 1.44 Hz; Left Eye Vertical: SPV 8.48°/s, amp 6.31°, freq 0.69 Hz; Fast Phase Direction 320.12° |
Interpretation of Left Dix-Hallpike positional nystagmus:
- Nystagmus is geotropic/mixed with both vertical and horizontal (torsional) components
- Fast phase direction ~320° (upper-left) is consistent with the expected nystagmus of left posterior canal BPPV (upbeat + left torsional with left ear down in DH)
- However, the slow phase velocities are mild (5–8 °/s; classical BPPV typically >10–15 °/s)
- The nystagmus appears to persist rather than fatigue within the short recording window shown
McClure-Pagnini (roll test): No horizontal nystagmus provoked in lateral positions — argues against horizontal canal BPPV.
8. Subjective Visual Vertical (SVV)
| Trial | Deviation | Direction |
|---|---|---|
| All 3 trials (CW, CCW, Blank) | 90° (Right) | AntiClockwise rotation |
This is a striking finding. Normal SVV deviation is ≤2–3°. A 90° deviation is massively abnormal. This indicates profound utricle/otolith dysfunction — the patient's perceived vertical is rotated 90° from true vertical. This level of SVV tilt is seen in:
- Severe acute unilateral utricle dysfunction
- Vestibular migraine with central otolithic involvement
- Rarely in thalamic or brainstem strokes
Given the absence of spontaneous nystagmus and preserved horizontal OKN, an acute stroke is less likely. The combination of 90° SVV with migraine history and central smooth pursuit/OKN findings strongly points to vestibular migraine with central pathway involvement.
Overall VNG Impression
Primary Diagnosis: Vestibular Migraine (VM)
This patient meets diagnostic criteria per Barany Society/IHS:
- ✅ At least 5 episodes of vestibular symptoms of moderate/severe intensity (spinning, position-induced vertigo)
- ✅ Current/prior migraine history (>10–15 years)
- ✅ Migraine features during vestibular episodes — phonophobia (loud sound irritation), osmophobia (fragrance-triggered headache), photophobia (lights-off triggering dizziness)
Supporting VNG Evidence for VM:
- Impaired smooth pursuit (especially horizontal at 0.4–0.6 Hz) — central pattern
- Severely impaired vertical OKN — central vestibular pathway sign
- Bilateral saccadic hypometria — cerebellar/central involvement
- No spontaneous nystagmus — argues against active peripheral lesion
- Massively abnormal SVV (90° right tilt) — severe otolithic dysfunction, consistent with VM
Secondary Finding: Left Posterior Canal BPPV (mild/equivocal)
- Mild positional nystagmus on left Dix-Hallpike with appropriate direction
- SPV mild (5–8 °/s), possibly subclinical
- Note: BPPV and VM frequently co-exist — Cummings Otolaryngology states: "Meniere disease and benign paroxysmal positional vertigo are commonly associated with migraine."
Recommended Management
Vestibular Migraine
- Lifestyle modification first — sleep hygiene, dietary triggers (caffeine, chocolate, processed cheese, strong fragrances as triggers), hydration, regular meals
- Vestibular/migraine diary — track triggers, episode frequency
- Pharmacotherapy options:
- Prophylaxis: Propranolol (beta-blocker), Amitriptyline (TCA), Topiramate, Valproate, Venlafaxine
- Acute: Triptans during vestibular attacks with headache
- Vestibular rehabilitation — helps with central compensation
BPPV (if symptomatic)
- Left Epley maneuver (for left posterior canal)
- Patient can be reassured — canalith repositioning is highly effective
Further Workup to Consider
- MRI brain with FLAIR (given central VNG signs and 90° SVV) — to rule out cerebellar/brainstem pathology
- Audiometry — baseline despite no current hearing complaints
- ENT/Neurotology referral recommended given complexity
Reference: Cummings Otolaryngology Head and Neck Surgery — Chapter 168, Vestibular Migraine; Vestibular Disorders Associated With Migraine
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