Vertigo

Jeremy Raab, MD and James J. Arnold, DO, FAAFP Reviewed 06/2017
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Subject: Vertigo

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BASICS

DESCRIPTION

  • A symptom, not a disease process. Among the potential causes are several life-threatening conditions. As such, the cause must be identified in order to determine the appropriate treatment.

  • Sensation of movement (“room spinning”) when no movement is actually occurring; results from peripheral or central causes or may be induced by medications/anxiety disorders

  • Important to distinguish between vertigo, presyncope (patient feels like they are going to black out; vision and hearing may become obscured), disequilibrium (off balance), and light-headedness (vague, inconsistent symptoms, no rotational component)

  • System(s) affected: nervous

  • Synonym(s): dizziness; acute vestibular neuritis; labyrinthitis; benign paroxysmal positional vertigo (BPPV)

EPIDEMIOLOGY

Incidence

  • Vertigo accounts for 54% of cases of dizziness reported in primary care; >90% of these patients are diagnosed with peripheral causes such as BPPV 1.

  • Predominant sex: female = male; women are more likely to experience central causes, particularly vertiginous migraine.

Geriatric Considerations

  • Elderly patients with risk factors for cerebrovascular disease (CVD) are more likely to experience central causes.

  • BPPV is commonly undiagnosed in the elderly and is an important risk factor for falls.

Prevalence

  • Ranges from 5% to 10% within the general population

  • Lifetime prevalence for BPPV is 2.4%.

ETIOLOGY AND PATHOPHYSIOLOGY

  • Dysfunction of the rotational velocity sensors of the inner ear results in asymmetric central processing. This is related to the combination of sensory disturbance of motion and malfunction of the central vestibular apparatus.

  • Peripheral causes: acute labyrinthitis, acute vestibular neuritis, BPPV (posterior canal 85-95%, lateral canal 5-15%), herpes zoster oticus, cholesteatoma, Ménière disease, otosclerosis, perilymphatic fistula, superior canal dehiscence syndrome, motion sickness 1,2; BPPV, vestibular neuritis, and Ménière disease account for 93% of all vertigo 2.

  • Central causes: cerebellar tumor, CVD, migraine, multiple sclerosis 1

  • Drug causes: psychotropic agents (antipsychotics, antidepressants, anxiolytics, anticonvulsants, mood stabilizers), aspirin, aminoglycosides, furosemide (diuretics), amiodarone, α-/β-blockers, nitrates, urologic medications, muscle relaxants, phosphodiesterase inhibitors (sildenafil), excessive insulin, ethanol, quinine, cocaine

  • Other causes: cervical, psychological

Genetics

Family history of CVD/migraines may indicate higher risk of central causes. 

RISK FACTORS

  • History of migraines

  • History of CVD/risk factors for CVD

  • Use of ototoxic medications

  • Trauma/barotrauma

  • Perilymphatic fistula

  • Heavy weight bearing

  • Psychosocial stress/depression

  • Exposure to toxins

GENERAL PREVENTION

If due to motion sickness, consider pretreatment with anticholinergics, such as scopolamine

DIAGNOSIS

HISTORY

  • Determine if true vertigo or not by asking, “When you have dizzy spells, do you feel light-headed or do you see the world spin around you?” This reliably differentiates vertigo from nonvertiginous dizziness 1,2[C].

  • Obtain other medical and medication history: recent use of ototoxic medications (e.g., aminoglycosides); history of alcohol, nicotine, and caffeine use; sexual history; history of CVD/risk factors for CVD 1,3.

  • Ask about duration of symptoms 2[C].

    • ▪ A few seconds: peripheral cause such as unilateral loss of vestibular function; late stages of Ménière disease
    • ▪ Several seconds to a few minutes: BPPV; perilymphatic fistula
    • ▪ Several minutes to 1 hour: posterior TIA; perilymphatic fistula
    • ▪ Hours: Ménière disease, migraine, acoustic neuroma
    • ▪ Days: early acute vestibular neuritis, CVA, migraine, MS
    • ▪ Weeks: psychogenic (constant symptoms without improvement)
  • Provoking factors that help distinguish different causes of vertigo 2[C]

    • ▪ Changes in head position: acute labyrinthitis, BPPV, cerebellar tumor, MS, perilymphatic fistula
    • ▪ Spontaneous episodes/no clear provoking factors: vestibular neuritis, TIA/CVA, Ménière disease, migraine, MS
    • ▪ Recent URI: vestibular neuritis
    • ▪ Stress: psychogenic causes, migraine
    • ▪ Immunosuppression: herpes zoster oticus
    • ▪ Changes in ear pressure, trauma, loud noises: perilymphatic fistula
  • Symptoms that help distinguish between common causes (does not include all, see differential diagnoses) 2,3[C]

    • ▪ Aural fullness: acoustic neuroma, Ménière disease
    • ▪ Ear/mastoid pain: acoustic neuroma, acute middle ear disease (AOM, herpes zoster oticus)
    • ▪ Facial weakness: acoustic neuroma, herpes zoster oticus
    • ▪ Focal neurologic findings: cerebellar tumor, CVD, MS
    • ▪ Headache: acoustic neuroma, migraine
    • ▪ Hearing loss: Ménière disease, acoustic neuroma, otosclerosis, labyrinthitis, herpes zoster oticus, transient ischemic attack (TIA), cholesteatoma, perilymphatic fistula
    • ▪ Imbalance: acute vestibular neuritis (moderate), cerebellar tumor (severe)
    • ▪ Phonophobia/photophobia: migraine
    • ▪ Rash: herpes zoster oticus
    • ▪ Tinnitus: acute labyrinthitis, acoustic neuroma, Ménière disease

PHYSICAL EXAM

  • Neurologic: cranial nerves. Consider the HINTS battery to when evaluating for a central cause 4[C].

    • ▪ Horizontal Head Impulse: Rapidly bring patient’s head to midline from 20 degrees. Patients with peripheral vertigo will show rapid saccades to refocus on target. In central vertigo, eyes will stay on target.
    • ▪ Direction-changing Nystagmus: Nystagmus typically is unidirectional. Nystagmus that changes direction with eye motion indicates a central lesion.
    • Test of Skew: Vertical eye movement during cover-uncover test indicates a central lesion. A normal test has no movement.
    • ▪ A combination of these findings is 96.8% sensitive, 98.5% specific for CVA/other central cause (HINTS positive) 4[C].
  • Balance

    • ▪ Peripheral: mild to moderate, able to walk
    • ▪ Central: severe, unable to walk
  • Dix-Hallpike maneuver 2[C]: Rapidly move the patient from seated to supine position with the head turned 45 degrees to the right. Observe for nystagmus and ask the patient if he or she is experiencing vertigo. Note: There may be 5 to 20 seconds of latency before nystagmus/vertigo begin. Wait until symptoms resolve and then return the patient to the sitting position. Always repeat on the left side.

    • ▪ The presence of extinguishing horizontal nystagmus is a positive test, consistent with peripheral causes and specifically posterior canal BPPV.
    • ▪ If induced nystagmus does not subside, consider central causes.
    • ▪ Vertical nystagmus always indicates a central cause.
    • ▪ In primary care, PPV of 83% for BPPV and NPV of 52%
    • ▪ If Dix-Hallpike is negative, check for lateral canal BPPV: With patient supine, rapidly rotate head 90 degrees. If nystagmus induced, wait for it to subside and then return to neutral. Repeat on other side. Nystagmus with this test suggests lateral canal BPPV 5[C].
  • Head and neck: tympanic membranes

    • ▪ Vesicles: herpes zoster oticus
    • ▪ Cholesteatoma
    • ▪ Infection
  • Cardiovascular: orthostatic changes in BP, dehydration/autonomic dysfunction

DIFFERENTIAL DIAGNOSIS

  • Acoustic neuroma

  • Anxiety disorder

  • Arrhythmia

  • BPPV (posterior or lateral canal)

  • Cerebellar degeneration, hemorrhage, or tumor

  • Dehydration

  • Eustachian tube dysfunction/middle ear effusion

  • Hypoglycemia

  • Labyrinthitis/labyrinthine concussion

  • Ménière disease

  • Multiple sclerosis

  • Orthostatic hypotension

  • Perilymphatic fistula

  • Parkinson disease

  • Peripheral neuropathy

  • Syphilis

  • Superior canal dehiscence syndrome

  • Vascular ischemia

  • Vertiginous migraine

  • Vestibular neuritis/ototoxicity

DIAGNOSTIC TESTS & INTERPRETATION

Initial Tests (lab, imaging)

  • Labs not routinely necessary and identify a cause in ≪1% of patients 2[C].

  • Start MRI if a central cause is suspected to rule out stroke. CT cannot reliably see the posterior fossa and will not show changes in the early stages of an infarct. Vertigo may be the only symptom of acute stroke 4[C].

  • ENT/audiology referral if Ménière disease is suspected for electronystagmography 1,2,4[C]

  • If acoustic neuroma is suspected, either CT or MRI to evaluate internal auditory canal 1,2,4[C]

Diagnostic Procedures/Other

Audiometry if acoustic neuroma or Ménière disease is suspected 

TREATMENT

GENERAL MEASURES

Treatments depend on cause. 
  • BPPV: Epley maneuver 1,3,5[A] and modified Epley maneuver 1[B] (Epley maneuver—YouTube)

  • Vestibular neuritis and labyrinthitis

    • ▪ Vestibular-suppressant medications 1[C],3
    • ▪ Vestibular rehabilitation exercises 1[B],3
    • ▪ No evidence to support improvement of symptoms with corticosteroid use 6[B]
  • Ménière disease (see separate topic) 1[B],3:

  • Vascular ischemia: prevention of future events through BP reduction, lipid lowering, smoking cessation, antiplatelet therapy, and anticoagulation, if necessary; MRI or CT if suspected 1,4[C],3

  • Vertiginous migraines: dietary and lifestyle modifications, vestibular rehab, prophylactic and abortive medications 1[B],3

  • Psychological: SSRIs are better than benzodiazepines for anxiety-related vertigo. Use slow titration to avoid worsening symptoms 1[B].

MEDICATION

Avoid use of medication in mild cases. Use for acute phase only (few days at most), as longer term use may impair adaptation/compensation by the brain 1. Medications not recommended for BPPV 1,3,5[C
  • Meclizine: 12.5 to 50 mg PO q4-8h 1

    • Dimenhydrinate: 25 to 100 mg PO, IM, or IV q4-8h 1 Precautions: prostatic hyperplasia, glaucoma
    • ▪ Adverse effects: sedation, xerostomia
    • ▪ Interactions: CNS depressants
  • Prochlorperazine: 5 to 10 mg PO or IM q6-8h; 25 mg rectally q12h; 5 to 10 mg by slow IV over 2 minutes 1

    • ▪ Contraindications: blood dyscrasias, age ≪2 years, hypotension
    • ▪ Precautions: acutely ill children, glaucoma, breast cancer history, impaired cardiac function, prostatic hyperplasia
    • ▪ Adverse effects: sedation, extrapyramidal effects
    • ▪ Interactions: phenothiazines, tricyclic antidepressants
  • Metoclopramide: 5 to 10 mg PO q6h, 5 to 10 mg slow IV q6h 1

    • ▪ Contraindications: concomitant use of drugs with extrapyramidal effects, seizure disorders
    • ▪ Precautions: history of depression, Parkinson disease, hypertension
    • ▪ Adverse effects: sedation, fluid retention, constipation
    • ▪ Interactions: linezolid, cyclosporine, digoxin, levodopa
  • Psychiatric causes 1

    • ▪ SSRIs for depression/anxiety 1[B]
    • Lorazepam (Ativan) 0.5 to 2 mg orally, IM, or IV q4-8h for short-term relief of more severe anxiety
    • Diazepam (Valium) 2 to 10 mg orally or IV q4-8h for short-term relief of more severe anxiety

Geriatric Considerations

Use vestibular-suppressant medications with caution due to increased risk of falls and urinary retention. 

Pregnancy Considerations

Meclizine and dimenhydrinate are pregnancy Category B. 

ISSUES FOR REFERRAL

Consider referral to otolaryngologist, ENT specialist, vestibular rehabilitation therapist, or neurologist if patient requires further care. 

ADDITIONAL THERAPIES

  • Epley maneuver/modified Epley maneuver for BPPV to displace calcium deposits in the semicircular canals 1,3,5[A]

    • ▪ Effective for short-term symptomatic improvement and for converting patient from positive to negative Dix-Hallpike maneuver 1[A] and some studies suggest long-term relief 1[C]
    • ▪ Contraindications: carotid stenosis, unstable cardiac disease, severe neck disease
  • Lateral canal BPPV may respond to barbecue roll maneuvers 5[C].

  • Vestibular rehabilitation exercises: ball toss, lying-to-standing, target-change, thumb-tracking, tightrope, walking turns 1[B]

ONGOING CARE

FOLLOW-UP RECOMMENDATIONS

Balance exercises should be adhered to for symptom reduction and return to normal activities of daily living (ADLs). 

Patient Monitoring

After 1 to 2 weeks, assess for the following: 
  • Recurrence of symptoms

  • New-onset symptoms

  • Medication-related adverse effects

  • Relief from vestibular rehabilitation exercises

DIET

  • Restricted salt intake for Ménière disease

  • Dietary modifications for vertiginous migraine

PATIENT EDUCATION

  • Reduce sodium intake (Ménière disease).

  • Avoid triggers such as caffeine/alcohol (vertiginous migraine).

PROGNOSIS

Depends on diagnosis and response to treatment 

COMPLICATIONS

  • Anxiety

  • Depression

  • Disability

  • Injuries from falls

REFERENCES

Swartz  R, Longwell  P. Treatment of vertigo. Am Fam Physician.  2005;71(6):1115–1122.  [View Abstract]
Labuguen  RH. Initial evaluation of vertigo. Am Fam Physician.  2006;73(2):244–251.  [View Abstract]
Post  RE, Dickerson  LM. Dizziness: a diagnostic approach. Am Fam Physician.  2010;82(4):361–368.  [View Abstract]
Yew  KS, Cheng  EM. Diagnosis of acute stroke. Am Fam Physician.  2015;91(8):528–536.  [View Abstract]
Bhattacharyya  N, Baugh  RF, Orvidas  L, et al. Clinical practice guideline: benign paroxysmal positional vertigo. Otolaryngol Head Neck Surg.  2008; 139(5 Suppl):S47–S81.  [View Abstract]
Fishman  JM, Burgess  C, Waddell  A. Corticosteroids for the treatment of idiopathic acute vestibular dysfunction (vestibular neuritis). Cochrane Database Syst Rev.  2011;(5):CD008607.  [View Abstract]

ADDITIONAL READING

  • Fife TD, Iverson DJ, Lempert T, et al. Practice parameter: therapies for benign paroxysmal positional vertigo (an evidence-based review): report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology.  2008;70(22):2067–2074.

  • Hilton M, Pinder D. The Epley (canalith repositioning) maneuver for benign paroxysmal positional vertigo. Cochrane Database Syst Rev.  2014;(12):CD003162.

SEE ALSO

  • Ménière Disease; Motion Sickness, Vertigo, Benign Paroxysmal Positional (BPPV)

  • Algorithm: Vertigo

CODES

ICD10

  • R42 Dizziness and giddiness

  • H81.10 Benign paroxysmal vertigo, unspecified ear

  • H81.49 Vertigo of central origin, unspecified ear

  • H81.399 Other peripheral vertigo, unspecified ear

  • H81.311 Aural vertigo, right ear

  • H81.20 Vestibular neuronitis, unspecified ear

  • H81.391 Other peripheral vertigo, right ear

  • H81.312 Aural vertigo, left ear

  • H81.23 Vestibular neuronitis, bilateral

  • H81.392 Other peripheral vertigo, left ear

  • H81.43 Vertigo of central origin, bilateral

  • H81.393 Other peripheral vertigo, bilateral

  • H81.41 Vertigo of central origin, right ear

  • H81.313 Aural vertigo, bilateral

  • H81.22 Vestibular neuronitis, left ear

  • H81.319 Aural vertigo, unspecified ear

  • H81.11 Benign paroxysmal vertigo, right ear

  • H81.42 Vertigo of central origin, left ear

  • H81.21 Vestibular neuronitis, right ear

  • H81.13 Benign paroxysmal vertigo, bilateral

  • H81.12 Benign paroxysmal vertigo, left ear

ICD9

  • 780.4 Dizziness and giddiness

  • 386.11 Benign paroxysmal positional vertigo

  • 386.2 Vertigo of central origin

  • 386.19 Other peripheral vertigo

  • 386.10 Peripheral vertigo, unspecified

  • 386.12 Vestibular neuronitis

SNOMED

  • 399153001 Vertigo (finding)

  • 404640003 Dizziness (finding)

  • 111541001 benign paroxysmal positional vertigo (disorder)

  • 38403006 Vertigo of central origin

  • 50438001 peripheral vertigo (disorder)

  • 186738001 Epidemic vertigo

CLINICAL PEARLS

  • Risk factors include migraines, CVD/CVD risk factors, ototoxin exposure/meds, trauma/barotrauma, perilymphatic fistula, heavy weight bearing, psychosocial stress.

  • Acute vertigo with a normal horizontal head impulse, direction-changing nystagmus, and skew deviation (HINTS positive) is highly sensitive and specific for CVA.

  • Nystagmus indicates a positive Dix-Hallpike test implies a peripheral cause. If nystagmus persists, investigate a central cause.

  • The Epley maneuver is recommended for the treatment of BPPV; the modified Epley can be performed at home.

  • Medications are not recommended for BPPV.

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