Identified by associated brainstem or cerebellar signs such as dysarthria, diplopia, dysphagia, hiccups, other cranial nerve abnormalities, weakness, or limb ataxia; depending on the cause, headache may be present. The nystagmus can take almost any form (i.e., vertical or multidirectional) but is often purely horizontal without a torsional component and changes direction with different directions of gaze. Central nystagmus is not inhibited by fixation. Central vertigo may be chronic, mild, and is usually not accompanied by tinnitus or hearing loss. It may be due to vascular, demyelinating, neurodegenerative, or neoplastic disease. Vertigo may be a manifestation of migraine or, rarely, of temporal lobe epilepsy.
Treatment: Vertigo - Treatment of acute vertigo consists of vestibular suppressant drugs for short-term relief (Table 51-2). They may hinder central compensation, prolonging the duration of symptoms, and therefore should be used sparingly.
- Vestibular rehabilitation promotes central adaptation processes and may habituate motion sensitivity and other symptoms of psychosomatic dizziness.
- BPPV may respond dramatically to repositioning exercises such as the Epley maneuver designed to empty particulate debris from the posterior semicircular canal (www.dizziness-and-balance.com/disorders/bppv/bppv.html).
- For vestibular neuritis, antiviral medications are of no proven benefit unless herpes zoster oticus is present. Some data suggest that glucocorticoids improve the likelihood of recovery in vestibular neuritis if given within 3 days of symptom onset.
- Ménière's disease may respond to a low-salt diet (1 g/d) or to a diuretic. Otolaryngology referral is recommended.
- Recurrent episodes of migraine-associated vertigo should be treated with antimigraine therapy (Chap. 49. Headache).
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For a more detailed discussion, see Walker MF, Daroff RB: Dizziness, and Vertigo, Chap. 28, p. 148, in HPIM-19. |