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What caused acute vertigo in two healthy women? That's the diagnostic challenge described by David Elisha, BS, of Tel Aviv University School of Medicine in Israel, and Ronen Nazarian, MD, of Cedars-Sinai Medical Center in Los Angeles, in .

Based on findings from a complete physical examination, the clinicians determined that the first patient, age 31, had benign paroxysmal positional vertigo (BPPV) of the right side.

After treating the patient, they obtained a detailed history in an effort to identify the cause. In describing her recent activities, the patient described using a handheld percussive massage gun daily, most recently on her neck and shoulders 12 hours before her symptoms developed.

The second patient was a 48-year-old woman who had experienced repeated episodes of BPPV. She reported having undergone many standard treatments that initially had relieved her symptoms for short periods of time. However, the BPPV symptoms kept recurring.

On her fourth visit to the medical center, the patient had a complete re-evaluation, during which she described using a massage gun regularly around her upper neck and occiput. On the advice of the team, the patient stopped using the massage device, after which she had no more episodes of BPPV.

The two patients received the same diagnostic evaluations -- specifically, a comprehensive assessment of vestibular functions, including gait, Romberg, Fukuda, nystagmus, fistula, head-shaking, and finger-to-nose tests. In both cases, the clinicians performed the Dix-Hallpike maneuver, which elicited positive nystagmus, and confirmed the BPPV diagnosis.

Repositioning maneuvers provided significant relief of symptoms in both patients, and they were advised to stop using their massage guns. Their symptoms did not recur.

Discussion

As the most common form of peripheral vertigo, BPPV has a prevalence of 3.2%. Most cases of BPPV occur due to displacement of otoconia within the semicircular canals of the inner ear, which in turn causes vertigo when moving the head, the authors explained.

is well-known as a risk factor for BPPV; however, the authors suggested that cases of BPPV associated with less severe vibrational injuries are likely underreported. They cited data linking BPPV with exposure to vibration in association with a variety of activities and tools, "such as using , undergoing dental procedures, and engaging in ."

"Associations between BPPV and handheld massage guns remain unexplored in existing literature," Elisha and Nazarian noted.

Handheld massage devices apply significantly more force than traditional devices, and their increasing availability has raised safety concerns about their use, the authors explained. Other case reports have linked these massage guns with cases of rhabdomyolysis and .

To assess the impact of handheld massage guns on the user, accurate measurement in force per cm² is crucial. "Handheld massage guns are advertised to deliver 14 to 32 kgs of no-stall force with up to 5,000 strokes per minute and an amplitude of up to 16 mm, distinguishing these from other massage devices in both force delivery and design," the authors wrote. When used on the head and shoulders, this degree of force has the potential to dislodge otoliths within the inner ear, and lead to BPPV in susceptible individuals.

The risk of BPPV increases with age, likely as a result of age-related deterioration. However, the two patients' cases are notable since they are both relatively young, the authors noted, "challenging typical age-related expectations, and highlighting the potency of the powerful vibration inflicted by massage guns."

Clinicians who are assessing patients who have BPPV, especially when it is recurrent, should ask about the use of massage devices to identify potential associations. Furthermore, a comprehensive examination and history should include other lifestyle factors that may be potential causes of (particularly recurrent) BPPV.

"This observational report emphasizes the importance of considering the use of percussive massage guns during the evaluation of potential BPPV diagnoses," Elisha and Nazarian wrote, as the condition can have a significant effect on quality of life. Recurrences could be reduced through awareness, cautious use of percussive massage devices, and prompt recognition and treatment of BPPV.

"Although these findings are preliminary, they align with previous research indicating an association between vibrational exposure and BPPV. Given this context, manufacturers should issue generalized warnings on vertigo risks associated with these devices, especially when used near the head and upper neck," they concluded.

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