Rush’s Dizziness Clinic: A Multidisciplinary Model for Complex Vestibular Disorders

How did the Dizziness Clinic come about?

Dr. Taber: The idea originated in otolaryngology, which had wanted a formal partnership with neurology to address complex vestibular presentations. When I joined Rush two years ago, I had a strong interest in dizziness and balance disorders, and we began developing a joint program. It took some time to establish workflows and cross-departmental coordination, but the clinic officially opened in the spring of 2025.

Dr. Elrakhawy: I came to Rush about a year ago with prior fellowship experience in otology and neurotology. One of my goals was to develop an integrated balance clinic, modeled after programs where ENT and neurology jointly evaluate patients. The opportunity to do that at Rush was a major draw.

What differentiates Rush’s clinic from others in Chicago?

Dr. Elrakhawy: While other centers manage vestibular disorders, Rush’s clinic is the only one in Chicago that systematically combines ENT and neurology evaluations on the same day. This model prevents patients from being shuttled between departments and ensures the entire spectrum of peripheral and central causes is assessed.

Dr. Taber: Dizziness can originate anywhere from the inner ear to cortical networks integrating visual and proprioceptive input. Because symptoms cross specialties, a joint clinic eliminates the fragmentation that often delays diagnosis.

How do you make a differential diagnosis in patients with persistent dizziness?

Dr. Taber: Our diagnostic cornerstone is a structured history emphasizing timing, triggers, and associated features (TiTrATE framework). A precise chronology often narrows the differential more effectively than testing alone. We localize symptoms to central versus peripheral pathways and use targeted vestibular and audiologic testing as confirmation.

Dr. Elrakhawy: We also recognize that dizziness reflects dysfunction in multiple sensory systems — visual, vestibular, and somatosensory. A detailed history and focused neurologic and otologic exam remain more informative than any single imaging or lab test.

What are the most common etiologies you see?

Dr. Elrakhawy: The leading cause in our cohort has been vestibular migraine, formerly termed “migraine-associated vertigo.” It’s historically under-recognized but highly prevalent. We also frequently diagnose benign paroxysmal positional vertigo (BPPV) due to otoconia displacement, vestibular neuritis, and persistent postural-perceptual dizziness (PPPD)—a chronic functional disorder of sensory reweighting.

Dr. Taber: PPPD is particularly interesting. It often develops after an acute vestibular event or major stressor, when the brain becomes visually dependent and fails to recalibrate multisensory inputs. Patients report non-spinning dizziness aggravated by motion or complex visual environments. We manage it with a combination of vestibular rehabilitation therapy, SSRIs or SNRIs, and cognitive behavioral therapy, which improve sensory integration and habituation.

How is the multidisciplinary evaluation structured?

Dr. Elrakhawy: Before their visit, patients are screened by audiology to ensure appropriateness for the clinic. On the evaluation day, they undergo comprehensive audiometric and vestibular testing in the morning — often including videonystagmography and balance assessment — followed by joint consultation with neurology and otolaryngology in the afternoon.

Dr. Taber: At the end of clinic, we meet with the audiologists to review all cases and establish a consensus diagnosis and treatment plan. This collaboration minimizes redundant testing and allows us to direct care efficiently, whether through migraine management, vestibular therapy, or referral to cardiology if orthostatic or cardiovascular causes are suspected.

What therapeutic approaches do you use?

Dr. Elrakhawy: Treatment is etiology-specific. For vestibular migraine, we employ standard migraine prophylactic agents — beta-blockers, tricyclic antidepressants, calcium-channel blockers or SNRIs — depending on comorbidities and prior therapy. If a patient is already on migraine-adjacent medication, we may adjust dosage or transition to an alternative with stronger vestibular efficacy.

Dr. Taber: For patients with extensive medication sensitivities, we use pharmacogenomic testing through commercial labs to guide selection. We also offer occipital nerve blocks and onabotulinumtoxinA (Botox) injections for chronic migraine, both of which can significantly reduce vestibular symptoms.

Dr. Elrakhawy: Beyond pharmacologic therapy, we often integrate vestibular physical therapy, CBT, and, in select cases, steroids or canalith repositioning maneuvers for BPPV. The multidisciplinary model allows for a flexible, patient-specific combination of these modalities.

How do you assess outcomes and guide future research?

Dr. Elrakhawy: We track patient-reported outcomes such as symptom frequency, return to baseline function, and changes in Dizziness Handicap Inventory scores. The clinic is only months old, but our goal is to build a prospective database to evaluate treatment efficacy and contribute to the literature on multidisciplinary dizziness care.

Dr. Taber: Because vestibular disorders overlap with migraine, anxiety and functional neurologic syndromes, systematically collected outcome data will help clarify which treatment combinations yield the best long-term benefit.