Drop attacks

By Marcello Cherchi, MD PhD

For patients

The phrase “drop attack” refers to an episode in which a patient feels abruptly thrown or shoved to the ground, without warning, and without loss of consciousness. Attacks such as these can arise from several inner ear problems and brain problems, consequently evaluation may involve checking several tests of inner ear function, and perhaps brain imaging.

For clinicians

Overview

The phrase “drop attack” refers to a clinical presentation in which there is no prodrome, there is abrupt onset of falling to the ground, abrupt offset of symptoms, and no loss of consciousness.  The broad differential diagnosis includes otologic, neurologic and cardiovascular etiologies.  Undertaking a screening otovestibular workup is reasonable.  If that is unremarkable, then depending on the history, referral to a sleep specialist or cardiologist may be warranted.

Definition

The phrase “drop attack” refers to a clinical presentation in which there is no prodrome, there is abrupt onset of falling to the ground, abrupt offset of symptoms, and no loss of consciousness. Patients use different descriptors, such as feeling “thrown” or “shoved” to the ground.

The absence of any prodrome or warning is an especially problematic feature of drop attacks, and can lead to injury.

Etiologies

Drop attacks have been reported in a broad range of diseases, with a differential diagnosis including:

  • Otologic
    • Otolithic catastrophe of Tumarkin as a late stage of Ménière’s disease (Baloh, Jacobson et al. 1990, Pyykko, Pyykko et al. 2020)
    • Perilymphatic fistula (Pace, Iannella et al. 2020)
    • Peripheral pathologies, undifferentiated (Ishiyama, Ishiyama et al. 2001, Ishiyama, Ishiyama et al. 2003, Lee, Yi et al. 2005)
    • Superior semicircular canal dehiscence (Brantberg, Ishiyama et al. 2005)
    • Vestibular paroxysmia (Kim, Kong et al. 2021)
  • Neurologic
    • Arteriovenous fistula (Oh, Yoon et al. 2011)
    • Benign hereditary chorea (Rosati, Berti et al. 2015)
    • Cataplexy, even in the absence of narcolepsy (Egel, Lee et al. 2012)
    • Chiari malformation (Bardella, Maleci et al. 1984, Straus, Foster et al. 2009)
    • Coffin-Lowry syndrome (Havaligi, Matadeen-Ali et al. 2007)
    • Cyst of the lateral ventricle (Bansal, Kumar et al. 2015)
    • Cyst of the third ventricle (Pollack, Schor et al. 1995, Zohrevandi, Monsef Kasmaie et al. 2015)
    • Epilepsy
      • Doose syndrome (Nickels, Kossoff et al. 2021)
      • Lennox-Gastaut syndrome (Gresham, Eiland et al. 2010, Verdian and Yi 2010, VanStraten and Ng 2012)
      • Rett syndrome (Ueda, Sood et al. 2017)
      • Seizures, undifferentiated (Maehara and Shimizu 2001, Jea, Vachhrajani et al. 2008, Sunaga, Shimizu et al. 2009)
    • Encephalitis (Vives-Rodriguez, Sivaraju et al. 2017)
    • Migraine (Ishiyama, Ishiyama et al. 2003, Pyykko, Pyykko et al. 2020)
    • Startle (Toelle, Wille et al. 2014)
  • Cardiovascular
    • Cardiac valve abnormalities (Bossert, Krakor et al. 2003)
  • Cryptogenic
    • One report documented “cryptogenic drop attacks: an affliction of women” (Stevens and Matthews 1973).

Diagnostic workup

Although the differential diagnosis listed above is impressive, practically, many of these patients do not present to an otoneurology or neuro-otology clinic. For example, the syndromic epilepsies (Doose syndrome, Lennox-Gastaut syndrome, Rett syndrome) have such dramatic clinical presentations that these patients are usually already under the care of an epileptologist who would be well aware of their association with drop attacks.

Consequently, from the otoneurological perspective, a reasonable workup may include:

  • Audiometry. Low frequency hearing loss may suggest Ménière’s disease. Conductive hyperacusis may suggest semicircular canal dehiscence.
  • Cervical and ocular vestibular evoked myogenic potentials with thresholds. An abnormally large response, with ipsilaterally reduced thresholds, may suggest semicircular canal dehiscence.
  • Other tests of unilateral vestibular function, such as video head impulse testing and videonystagmography. These may suggest lateralizing pathology, such as a prior bout of vestibular neuritis.
  • If any otovestibular test results are compatible with semicircular canal dehiscence, then consider a temporal bone CT.
  • Consider MRI of the brain and internal auditory canals without and with contrast. This may detect structural otologic lesions, Chiari malformations, ventricular cysts and cerebral malformations.

If all the above are unrevealing, then consider:

  • Referral to a sleep disorders neurology to be evaluated for cataplexy.
  • If the history is ambiguous regarding loss of consciousness, then consider referral to cardiology.

Although migraine is on the differential diagnosis of drop attacks, I have never seen migraine presenting in this way. Such presentation must be exceedingly rare, and in any case would be a diagnosis of exclusion, thus I would be hesitant to treat empirically for presumptive migraine as an initial management strategy for drop attacks.

References

Baloh RW, Jacobson K, Winder T (1990) Drop attacks with Meniere’s syndrome. Ann Neurol 28: 384-7. doi: 10.1002/ana.410280314

Bansal A, Kumar A, Sharma MC, Purkait S, Sharma BS (2015) Lateral ventricular cystic choroid plexus papilloma presenting with recurrent drop attacks: A rare manifestation of a rare variant. Neurol India 63: 619-21. doi: 10.4103/0028-3886.162095

Bardella L, Maleci A, Di Lorenzo N (1984) [Drop attack as the only symptom of type 1 Chiari malformation. Illustration by a case]. Riv Patol Nerv Ment 105: 217-22.

Bossert T, Krakor R, Garbade J, Mohr FW (2003) Fibroelastoma of the aortic valve causing drop attack. Eur J Cardiothorac Surg 24: 639. doi: 10.1016/s1010-7940(03)00442-1

Brantberg K, Ishiyama A, Baloh RW (2005) Drop attacks secondary to superior canal dehiscence syndrome. Neurology 64: 2126-8. doi: 10.1212/01.WNL.0000165953.48914.B0

Egel RT, Lee A, Bump T, Javois A (2012) Isolated cataplexy in the differential diagnosis of drop attacks: a case of successful clinical diagnosis and treatment. Case Rep Neurol Med 2012: 757586. doi: 10.1155/2012/757586

Gresham J, Eiland LS, Chung AM (2010) Treating Lennox-Gastaut syndrome in epileptic pediatric patients with third-generation rufinamide. Neuropsychiatr Dis Treat 6: 639-45. doi: 10.2147/NDT.S6465

Havaligi N, Matadeen-Ali C, Khurana DS, Marks H, Kothare SV (2007) Treatment of drop attacks in Coffin-Lowry syndrome with the use of sodium oxybate. Pediatr Neurol 37: 373-4. doi: 10.1016/j.pediatrneurol.2007.06.025

Ishiyama G, Ishiyama A, Baloh RW (2003) Drop attacks and vertigo secondary to a non-meniere otologic cause. Arch Neurol 60: 71-5. doi: 10.1001/archneur.60.1.71

Ishiyama G, Ishiyama A, Jacobson K, Baloh RW (2001) Drop attacks in older patients secondary to an otologic cause. Neurology 57: 1103-6. doi: 10.1212/wnl.57.6.1103

Jea A, Vachhrajani S, Johnson KK, Rutka JT (2008) Corpus callosotomy in children with intractable epilepsy using frameless stereotactic neuronavigation: 12-year experience at the Hospital for Sick Children in Toronto. Neurosurg Focus 25: E7. doi: 10.3171/FOC/2008/25/9/E7

Kim S, Kong SK, Lee JM, Oh SJ (2021) Drop Attack Treated by Microvascular Decompression of the Superior Vestibular Nerve. Ear Nose Throat J: 1455613211043672. doi: 10.1177/01455613211043672

Lee H, Yi HA, Lee SR, Ahn BH, Park BR (2005) Drop attacks in elderly patients secondary to otologic causes with Meniere’s syndrome or non-Meniere peripheral vestibulopathy. J Neurol Sci 232: 71-6. doi: 10.1016/j.jns.2005.01.012

Maehara T, Shimizu H (2001) Surgical outcome of corpus callosotomy in patients with drop attacks. Epilepsia 42: 67-71. doi: 10.1046/j.1528-1157.2001.081422.x

Nickels K, Kossoff EH, Eschbach K, Joshi C (2021) Epilepsy with myoclonic-atonic seizures (Doose syndrome): Clarification of diagnosis and treatment options through a large retrospective multicenter cohort. Epilepsia 62: 120-127. doi: 10.1111/epi.16752

Oh HJ, Yoon SM, Kim SH, Shim JJ (2011) A case of pial arteriovenous fistula with giant venous aneurysm and multiple varices treated with coil embolization. J Korean Neurosurg Soc 50: 248-51. doi: 10.3340/jkns.2011.50.3.248

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Pyykko I, Pyykko N, Manchaiah V (2020) Vestibular drop attacks in Meniere’s disease and its association with migraine. Eur Arch Otorhinolaryngol 277: 1907-1916. doi: 10.1007/s00405-020-05890-3

Rosati A, Berti B, Melani F, Cellini E, Procopio E, Guerrini R (2015) Recurrent drop attacks in early childhood as presenting symptom of benign hereditary chorea caused by TITF1 gene mutations. Dev Med Child Neurol 57: 777-9. doi: 10.1111/dmcn.12644

Stevens DL, Matthews WB (1973) Cryptogenic drop attacks: an affliction of women. Br Med J 1: 439-42. doi: 10.1136/bmj.1.5851.439

Straus D, Foster K, Zimmerman F, Frim D (2009) Chiari drop attacks: surgical decompression and the role of tilt table testing. Pediatr Neurosurg 45: 384-9. doi: 10.1159/000260909

Sunaga S, Shimizu H, Sugano H (2009) Long-term follow-up of seizure outcomes after corpus callosotomy. Seizure 18: 124-8. doi: 10.1016/j.seizure.2008.08.001

Toelle SP, Wille D, Schmitt B, Scheer I, Thony B, Plecko B (2014) Sensory stimulus-sensitive drop attacks and basal ganglia calcification: new findings in a patient with FOLR1 deficiency. Epileptic Disord 16: 88-92. doi: 10.1684/epd.2014.0629

Ueda K, Sood S, Asano E, Kumar A, Luat AF (2017) Elimination of medically intractable epileptic drop attacks following endoscopic total corpus callosotomy in Rett syndrome. Childs Nerv Syst 33: 1883-1887. doi: 10.1007/s00381-017-3567-y

VanStraten AF, Ng YT (2012) Update on the management of Lennox-Gastaut syndrome. Pediatr Neurol 47: 153-61. doi: 10.1016/j.pediatrneurol.2012.05.001

Verdian L, Yi Y (2010) Cost-utility analysis of rufinamide versus topiramate and lamotrigine for the treatment of children with Lennox-Gastaut Syndrome in the United Kingdom. Seizure 19: 1-11. doi: 10.1016/j.seizure.2009.10.003

Vives-Rodriguez A, Sivaraju A, Louis ED (2017) Drop attacks: A clinical manifestation of LGI1 encephalitis. Neurol Clin Pract 7: 442-443. doi: 10.1212/CPJ.0000000000000390

Zohrevandi B, Monsef Kasmaie V, Asadi P, Tajik H (2015) Third Ventricle Colloid Cyst as a Cause of Sudden Drop Attacks of a 13-Year-Old Boy. Emerg (Tehran) 3: 162-4.

Page first published on February 21, 2023. Page last updated on November 8, 2025

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