Topic Editor: Grant E. Fraser, M.D., FRACGP, FACRRM, ASTEM
Review Date: 3/18/2013
Definition
Vertigo is a sensorimotor syndrome that involves the unpleasant perception of movement of either one's own body or the environment, or both. Sensation can include swaying, rotation, or both.
Description
- Vertigo can occur due to central or peripheral causes. Most cases are due to benign paroxysmal positional vertigo (BPPV), acute vestibular neuronitis, or Ménière's disease. Other causes include cerebrovascular disease, intracranial neoplasms, migraine, multiple sclerosis, perilymphatic fistulas, and psychological disorders
- Vertigo may be either rotatory or postural. In cases of rotatory vertigo, patients complain of the sensation of being on a "merry-go-round,", whereas in postural vertigo, there is a sensation of "being on a boat." In many cases, patients complain of dizziness or lightheadedness with no sensation of movement
- Accompanying symptoms may include attacks of tinnitus, hearing impairment, and/or a pressure sensation in the ear, typical of Ménière's disease
- Symptoms such as diplopia, sensory disturbances, dysphagia, dysarthria, and/or paralysis of arms or legs, generally indicate a central neurological etiology
- Headache or a history of migraine may be more indicative of vestibular migraine, brainstem ischemia, or posterior fossa hemorrhage
- Generally, vertigo has a good prognosis. Management consists of medication, physical therapy, psychotherapy, and, in some cases, surgery
Epidemiology
Incidence/Prevalence
- Vertigo is a common problem in the general population with a lifetime prevalence of 7%
- A survey conducted among the general population indicates a 1-year prevalence for vertigo, migrainous vertigo, and benign paroxysmal positional vertigo of 4.9%, 0.89% and 1.6% respectively
- Another review indicates the 1-year incidence of vertigo among the general adult population is 1.4%
Age
- Benign paroxysmal positional vertigo (BPPV) frequently occurs spontaneously between 50–70 years of age. In younger populations, BPPV is the commonest cause of vertigo after head injury
Gender
- BPPV in one survey found a prevalence of 3.2% in females and 1.6% in males
Risk factors
- Advanced age
- Barotrauma
- Changes in ear pressure
- Excessive straining
- Exposure to toxins
- Head trauma
- Heavy weight bearing
- Loud noise exposure
- Migraine
- Ototoxic medications
- Perilymphatic fistula
- Psychosocial stressors
Etiology
- Peripheral causes
- Acute labyrinthitis
- Acute vestibular neuronitis (vestibular neuritis)
- BPPV
- Cholesteatoma
- Herpes zoster oticus (Ramsay Hunt syndrome)
- Ménière's disease (Ménière's syndrome, endolymphatic hydrops)
- Otosclerosis
- Perilymphatic fistula
- Central causes
- Cerebellopontine angle tumor
- Cerebrovascular disease such as transient ischemic attack or stroke (often vertebrobasilar distribution)
- Migraine
- Multiple sclerosis
- Other causes
- Cervical vertigo
- Drug-induced vertigo
- Psychological
History
- Determine whether the patient has true vertigo or whether there are other causes of dizziness. Ask whether the patient feels light-headed, or if objects seem to be spinning during a dizzy spell. Spinning suggests that the patient has true vertigo
- The next steps include identification of whether the vertigo seems to be of central or peripheral etiology. This determination, can be made by gathering information on the timing and duration of vertigo, provoking or aggravating factors, and identifying symptoms associated with episodes of vertigo
- Timing and duration of vertigo:
- In cases of recurrent spontaneous vertigo, a history of episodes lasting for a few minutes suggest transient ischemic attack (TIA)
- For isolated vertigo, determination of associated risk factors for vascular disease and duration of vertigo may help identify posterior circulation TIA as the likely cause of symptoms
- Spontaneous vertigo lasting for hours characterizes peripheral disorders, such as Ménière's disease. Patients with Ménière's disease usually have repeated vertiginous episodes with cumulative sensorineural hearing loss and fluctuating tinnitus
- Vertigo lasting <1 minute and provoked by sudden change in position such as turning the head, looking up, or turning over in bed is most likely to be BPPV
- Spontaneous vertigo lasting more than a day may have a central or peripheral cause; when central, will often be due to a stroke within the vertebrobasilar vascular distribution
- Peripheral causes are often associated with vestibular neuritis or labyrinthitis
- Cases of vertigo with acute stroke commonly have a very rapid onset while those with inflammatory conditions have slow onset over hours. Ataxia associated with central vertigo is more severe than with peripheral vertigo
- Some sources indicate that patients with acute peripheral vertigo often do not require assistance while standing, whereas patients with central vertigo need support in order to stand. It is important to note that this generalization fails to have sensitivity or specificity and some patients with peripheral vertigo have profound difficulty with ambulation
- Provoking factors and the clinical pattern associated with vertigo
- Consider BPPV if the symptoms occur only with change of position, such as turning over in bed, bending at the waist then straighten, or on hyperextension of the neck
- Patients with vestibular neuritis and labyrinthitis have a history of preceding viral illness in about 50% of cases
- Vertigo associated with migraine can thus be related to provocative factors causing migraine
- Vertigo due to perilymphatic fistula can be provoked by sneezing or movement that place the affected ear downward
- Nystagmus and vertigo occurring due to loud noises or sounds at a particular frequency indicate a peripheral cause for vertigo (Tullio's phenomenon)
- Nystagmus associated with peripheral vertigo is commonly horizontal and rotational, decreases or disappears when the patient focuses the gaze, and is typically triggered by some provoking factor. Nystagmus associated with central vertigo is purely horizontal, vertical, or rotational; and has no change when the patient focuses the gaze. Central causes tend to result in nystagmus of longer duration
- A history of anxiety or panic attacks associated with vertigo may indicate hyperventilation syndrome as a cause
- Cases of vertigo with hearing loss are mainly peripheral except cerebrovascular events where there is involvement of the internal auditory artery or anterior inferior cerebellar artery
- If there is ear pain along with vertigo, it is reasonable to consider acute middle ear disease, invasive disease of the temporal bone, or meningeal irritation
- Nausea or vomiting associated with vertigo is found in cases of acute vestibular neuronitis and in severe episodes of Ménière's disease and BPPV. Nausea and vomiting tend to be less severe in central causes of vertigo
- Associated symptoms such as altered level of consciousness, ataxia, dysarthria, paresthesia, sensory or motor function changes, vision or hearing changes, or weakness indicate central causes of vertigo such as cerebrovascular disease, neoplasm, or multiple sclerosis
- Cases of migrainous vertigo can present with other symptoms related to migraine, including characteristic headache and other associated symptoms such as nausea, vomiting, photophobia, and phonophobia
- Other factors: Patient's medical history including drug use, trauma, or toxin exposure may help identify the cause of vertigo. The patient's age may provide a reasonable clue to the underlying cause. Elderly patients, particularly those with diabetes or chronic hypertension are at increased risk for vertigo due to cerebrovascular issues
Physical findings on examination
Physical examination should include neurologic, cardiovascular, and head and neck examinations
Neurological examination
- Examine the cranial nerves for signs of palsy, sensorineural hearing loss, and nystagmus
- Spontaneous nystagmus is a common sign in peripheral vertigo with lesions of the labyrinth and cranial nerve VIII (vestibulocochlear). Vertical nystagmus has 80% sensitivity for vestibular nuclear or cerebellar vermis lesions
- Acute vestibular neuronitis consistently shows spontaneous horizontal nystagmus with or without rotatory nystagmus
- Patients with peripheral vertigo are usually able to walk but exhibit impaired balance, whereas cases of central vertigo often show a higher degree of instability with patients frequently unable to walk or stand without falling
- Vestibular or proprioceptive issues consistently show a positive Romberg's sign. It should be noted that a positive Romberg's sign is not particularly useful in diagnosing vertigo
- The Dix-Hallpike maneuver can be useful in diagnosing BPPV. A positive Dix-Hallpike maneuver is diagnostic for BPPV; however, if the maneuver doesn't yield results, it is not very reliable in ruling out BPPV as the cause of the patient's symptoms. If the intensity of induced symptoms subsides after repeated maneuvers, then consider peripheral vertigo; if symptoms do not subside, consider central vertigo
- A positive Dix-Hallpike maneuver and a history of vertigo +/- vomiting indicate a peripheral vestibular disorder
- Consider central vertigo if, after Dix-Hallpike maneuver, the patient manifests immediate vertical or torsional nystagmus, and the induced symptoms do not decrease with repeated maneuvers
Head and neck examination- Examine the tympanic membrane for vesicles [e.g., to identify a peripheral cause such as herpes zoster oticus (Ramsay Hunt syndrome)] or cholesteatoma
- A positive Hennebert's sign (pushing on the tragus and external auditory meatus of the affected side induces vertigo or nystagmus) suggests the presence of a perilymphatic fistula. Patients with a perilymphatic fistula or anterior semicircular canal dehiscence may present with vertigo after a valsalva maneuver (e.g. forceful exhalation against closed airway which is usually done with plugged nose and closed mouth). However, this finding has limited clinical diagnostic value
Cardiovascular examination- Postural vital signs should be obtained, with abnormal findings being a systolic blood pressure decrease of 20 mmHg, diastolic blood pressure decrease of 10 mmHg, or pulse increase of 30 beats per minute between the lying and standing positions
LD
Blood test findings
- Blood tests such as electrolytes, glucose, Complete blood count, and thyroid function tests may be helpful in cases where patients with vertigo exhibit signs and symptoms suggesting other causative conditions. These tests help to determine the cause of vertigo in <1% of patients with dizziness
- In most cases, patients with vertigo do not require any blood tests
Radiographic findings
- Consider magnetic resonance imaging (MRI) with angiography (MRA) of the brain, including the vertebral arteries (where indicated), in patients with neurologic symptoms, cerebrovascular disease risk factors, or progressive unilateral hearing loss
- CT Angiography of the vertebrobasilar arteries or CT brain may also be indicated in selected cases
Other diagnostic test findings
- Audiometry may be required in suspected cases of acoustic neuroma or Ménière's disease
General treatment items
- Vestibular nuclei neurons have a complex collection of receptors including GABA-A, GABA-B, NMDA, Histamine (H1, H2, & H3), serotonin 5HT1 and 5HT2, adrenergic a-1 and a-2 receptors, ß receptors, cholinergic muscarinic and nicotinic receptors, opioid receptors, and even cannabinoid CB1 receptors. Due to this wide range of receptors, the range of medications which can be utilized for vertigo is quite broad
- Medications which are useful in management of vertigo include anticholinergics, antihistamines, benzodiazepines, calcium channel antagonists, and dopamine receptor antagonists. Generally, medications are useful for treating acute cases of vertigo of a few hours to several days duration
- Anticholinergics and antihistamines are recommended for treating nausea associated with vertigo
- Vestibular suppressants such as such as anticholinergics and benzodiazepines may modify symptom intensity, and are used in cases of Ménière's disease and vestibular neuritis
- Calcium channel antagonists may be effective in cases where the underlying etiology is vestibular migraine
- Salt restriction and diuretics may be useful in Ménière's disease to prevent flare-ups
- No drug treatments are recommended in most cases of BPPV or bilateral vestibular paresis
- Prophylactic agents such as calcium channel antagonists, tricyclic antidepressants, and beta-blockers are often employed in cases of vertigo associated with migraine
- Varied approaches including trials of vestibular suppressants and physical therapy are recommended in cases of stroke or other structural lesions of the brainstem or cerebellum
- Benzodiazepines are useful in cases of psychogenic vertigo occurring with panic disorder, anxiety disorder, or agoraphobia. Treatment may enhance the action of gamma-aminobutyric acid (GABA) in the central nervous system (CNS), and relieve vertigo and anxiety
- Vestibular rehabilitation exercises can be useful in cases of vertigo requiring ongoing management. These exercises train the brain to use alternative visual and proprioceptive cues to maintain balance and gait
- Management of specific disorders
- Benign paroxysmal positional vertigo (BPPV): BPPV is caused by deposition of calcium debris especially in the posterior semicircular canals. It is not recommended to use medications in this case. Vertigo improves with head rotation maneuvers (canalith repositioning procedure, Epley maneuver, or the modified Epley maneuver) which displace free-moving calcium deposits back to the vestibule. Canalith repositioning maneuver is not universally recommended and the patient may be required to remain upright for 24 hours after this procedure. Canalith repositioning procedures include the following contraindications:
- Severe carotid stenosis
- Unstable heart disease
- Severe neck disease (cervical spondylosis with myelopathy or advanced rheumatoid arthritis)
- Vestibular neuronitis and labyrinthitis: Treatment consists of relieving symptoms using vestibular suppressant medications followed by vestibular exercises. After acute treatment of vertigo with medication, starting twice-daily vestibular rehabilitation exercises (depending upon tolerance) to achieve more rapid and complete vestibular compensation
- Ménière's disease (or endolymphatic hydrops): Low-salt diet and diuretics especially the combination of hydrochlorothiazide and triamterene commonly reduce vertigo. These measures are less effective in treating hearing loss and tinnitus. Rarely, surgical procedures such as decompression with an endolymphatic shunt or cochleosacculotomy are required in cases resistant to dietary modification and diuretics. Vestibular hair cell ablation with intratympanic injection of gentamicin can also be effective. Surgery is generally reserved for cases of severe, refractory Ménière's disease
- Vascular ischemia: Management of acute vertigo due to cerebellar or brainstem stroke includes vestibular suppressant medication and minimal head movement for the first day. Medication is tapered as tolerated and vestibular rehabilitation exercises are initiated. Cases of symptomatic critical vertebral artery stenosis refractory to medical management should be considered for vertebrobasilar stenting
- Migraine headaches: Cases of vertiginous migraine may respond to migraine treatment such as:
- Dietary reduction or elimination of aspartame, chocolate, caffeine, and alcohol
- Lifestyle modifications such as exercise, stress reduction, improving sleep patterns
- Vestibular rehabilitation exercises
- Medications: benzodiazepines, beta blockers, tricyclic antidepressants, selective serotonin reuptake inhibitors (SSRIs), calcium channel blockers and antiemetics
- Psychiatric disorders: Vertigo can commonly occur in patients with panic disorder or generalized anxiety disorder, and less frequently with depression. Vestibular suppressants and benzodiazepines are commonly used to treat dizziness in such cases. These agents typically provide only transient or incomplete relief. Consider SSRIs such as citalopram, fluoxetine, paroxetine, and sertraline in such cases, as more complete relief may occur. Cognitive behavior therapy may also be helpful in these anxiety disorders. Vestibular rehabilitation exercises in addition to cognitive behavior therapy in older patients help to improve gait speed and symptoms of dizziness
Medications indicated with specific doses
- Diazepam [Oral]
- Diazepam [IM/IV]
- Dimenhydrinate [IM/IV]
- Lorazepam [Oral]
- Lorazepam [IM/IV]
- Meclizine
- Metoclopramide [Oral]
- Metoclopramide [IM/IV]
- Prochlorperazine [Oral]
- Prochlorperazine [IM/IV]
- Promethazine [Oral]
- Promethazine [IM/IV]
Dietary or activity restrictions
- A sodium-free diet may alleviate symptoms of Ménière's disease
- Vertiginous migraine may improve with reduction or elimination of aspartame, chocolate, caffeine, and alcohol
Disposition
Admission criteria
- Acute suppurative labyrinthitis
- Cerebellar infarct/hemorrhage
- Intracranial mass or infection
- Intractable nausea/vomiting
- Patients who are unable to safely ambulate
- Vertebrobasilar insufficiency
Discharge criteria
- Diagnosis of peripheral vertigo, able to maintain oral intake and ambulate
