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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)
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.
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.
Ranges from 5% to 10% within the general population
Lifetime prevalence for BPPV is 2.4%.
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
History of migraines
History of CVD/risk factors for CVD
Use of ototoxic medications
Heavy weight bearing
Exposure to toxins
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].
Provoking factors that help distinguish different causes of vertigo 2[C]
Symptoms that help distinguish between common causes (does not include all, see differential diagnoses) 2,3[C]
Neurologic: cranial nerves. Consider the HINTS battery to when evaluating for a central cause 4[C].
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.
Head and neck: tympanic membranes
Cardiovascular: orthostatic changes in BP, dehydration/autonomic dysfunction
BPPV (posterior or lateral canal)
Cerebellar degeneration, hemorrhage, or tumor
Eustachian tube dysfunction/middle ear effusion
Superior canal dehiscence syndrome
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]
BPPV: Epley maneuver 1,3,5[A] and modified Epley maneuver 1[B] (Epley maneuver—YouTube)
Vestibular neuritis and labyrinthitis
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].
Meclizine: 12.5 to 50 mg PO q4-8h 1
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
Metoclopramide: 5 to 10 mg PO q6h, 5 to 10 mg slow IV q6h 1
Psychiatric causes 1
Epley maneuver/modified Epley maneuver for BPPV to displace calcium deposits in the semicircular canals 1,3,5[A]
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]
Recurrence of symptoms
Medication-related adverse effects
Relief from vestibular rehabilitation exercises
Restricted salt intake for Ménière disease
Dietary modifications for vertiginous migraine
Reduce sodium intake (Ménière disease).
Avoid triggers such as caffeine/alcohol (vertiginous migraine).
Injuries from falls
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.
Ménière Disease; Motion Sickness, Vertigo, Benign Paroxysmal Positional (BPPV)
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
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
399153001 Vertigo (finding)
404640003 Dizziness (finding)
111541001 benign paroxysmal positional vertigo (disorder)
38403006 Vertigo of central origin
50438001 peripheral vertigo (disorder)
186738001 Epidemic vertigo
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.