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Editors

SatuLamminmäki
SariAtula

Vertigo

Essentials

  • Benign postural vertigo, cervical vertigo, orthostatic hypotension and vestibular neuronitis should be recognized without extensive further examinations.
  • If vertigo is associated with neurological symptoms or findings, further investigations are needed.
    • It may be caused by a disorder of the cerebral circulation (TIA, cerebral infarction or haemorrhage). If less than 2 weeks have elapsed since the symptom start, the patient is referred to hospital examinations as an emergency case.
  • In cases involving acute impairment of hearing, the patient is referred to an ear specialist for an assessment, the latest, on the next working day.
  • In recurring or prolonged vertigo, the cause must be found out.
  • Vertigo-inducing medication is checked and its dosage reduced if possible.
  • Usually it is not worthwhile to treat symptomatic vertigo with drugs. Anti-nausea medication may be used in the case of severe nausea associated with vertigo.

Aetiology

  • Vertigo is mainly caused by organic malfunction. The most common causes of vertigo (not in the order of frequency) include:
    • tension neck
    • benign postural vertigo Benign Paroxysmal Positional Vertigo (Bppv)
    • orthostatic hypotension (when standing up; often associated with low blood pressure levels and occurs especially in the elderly)
    • vestibular neuronitis (acute-onset vestibular dysfunction)
    • Otitis with severe symptoms
    • Ménière's disease Ménière's Disease
    • circulatory disturbances of the cerebellum and brain stem (TIA, cerebral infarction), when associated with other symptoms Cerebral Infarction (Ischaemic Stroke)
    • cerebellar atrophy (usually associated with long-term excessive use of alcohol)
    • Multifactorial vertigo related to the ageing process in the elderly (involving, for example, the brain, eyes, organs of balance, peripheral sense of posture, orthostatism, adverse effects of drugs)
    • panic attack (hyperventilation).
  • The cause remains unexplained in about 10% of cases despite extensive examinations.
  • Vertigo induced by excessive medication is common; medication list should always be investigated when a patient has vertigo.

Case history

  • A thorough interview is the most important part of diagnostics.
  • What kind of symptom does the patient have: is the vertigo rotatory or does it create a sense of falling (feeling off-balance), or is it about other difficulties with balance, (pre)syncope or undefined feeling of dizziness?
    • Balance problems can be caused by e.g. diseases of the peripheral nervous system (polyneuropathy) or of the cerebellum.
    • Rotatory (carousel-type) vertigo is primarily of inner ear origin.
    • Vertigo that causes a falling sensation may have its origin in tension neck, the cervical spine or the brain, depending also on its grade of severity.
  • Accompanying symptoms
    • Paralysis/paresis, coordination difficulties, double vision, or difficulties in speech production suggest a disturbance in cerebral circulation.
    • Hearing impairment, tinnitus or ear pain suggest otogenic aetiology.
    • Palpitation, dyspnoea or sensations in the chest area may suggest an arrhythmia, pulmonary embolism or panic attack.
  • Did the vertigo begin acutely or has it persisted for a longer time?
    • Paroxysmal acute vertigo and precipitating factor
      • Benign paroxysmal positional vertigo (changing position)
      • Orthostatism (standing up)
      • Vertigo associated with pharmaceuticals or toxic substances
      • Vertigo associated with physical exertion may be a vagus reflex or a sign of cardiac arrhythmia.
    • Paroxysmal acute vertigo with no precipitating factor
      • TIA (duration often some minutes only)
      • Ménière's disease (duration tens of minutes)
      • Vestibular migraine
      • Panic attack, phychological causes
      • Cardiac causes
      • Epilepsy, MS
    • Non-paroxysmal acute vertigo
      • Vestibular neuronitis, labyrinthitis (duration days-weeks)
      • Vertigo associated with sudden hearing loss
      • Disturbance of the cerebral circulation
    • Long-lasting (weeks-years) vertigo
      • Adverse effects of pharmaceuticals
      • Age-related vertigo/dizziness
      • Vertigo originating from the cervical spine or tension neck
        • ”Boat deck vertigo”, a momentary need to take a sidestep, headache, difficulties with visual acuity, nausea, and tenderness of the scalp.
      • Psychological causes
      • Vestibular dysfunction
      • Cerebellar degeneration
  • Revision of medication

Clinical examination

  • Observation of nystagmus (most reliably with Frenzel goggles that magnify the eyes)
    • In paroxysmal vertigo also during the Dix-Hallpike test.
    • In otogenic vertigo can be observed during acute vertigo symptom
    • Rarely occurring vertical nystagmus usually indicates a disorder in the brain stem area.
  • HINTS test (Head Impulse, Nystagmus, Test of Skew, see e.g. http://www.emra.org/emresident/article/hints-exam/) is intended to be used in patients who are experiencing vertigo at the time of examination and whose predominant symptom is acute-onset vertigo.
    • The head jerk test reveals possible impairment of the horizontal semicircular canal: when the patient's head is suddenly jerked towards the affected side the gaze does not remain fixed but a delayed corrective movement is observed.
  • Disturbance of cerebral circulation is suggested by
    • normal finding in the head jerk test (corrective movement suggests labyrinthine cause)
    • direction-changing nystagmus that follows gaze
    • vertical dysconjugation of the eyes (disturbance in the vertical binocular movement).
  • Examination of the nuchal area: muscular tension, cervical spine movements and possible pain or tenderness caused by them
  • Neurological, otological and circulatory examination
    • The Romberg test and the blind walking test (the patient undertakes stationary stepping with eyes closed, the body should not rotate more than 45°) evaluate the degree of objective disturbance in balance.
    • Coordination tests
    • Cranial nerves, muscle strengths, tendon reflexes
    • Tympanic membranes (otitis, labyrinthine irritation)
    • Tuning fork tests (pictures 1 2) to define possible hearing impairment
    • Blood pressure sitting and standing, orthostatism test if needed Brief Orthostatic Test
    • Auscultation of the heart

Further investigations

  • Examinations within primary care, as necessary
    • ECG and, if needed, Holter-monitoring (possible cardiac arrhythmias)
    • An audiogram is indicated if an otogenic disease is suspected, especially if the patient has spinning dizziness of longer duration (tens of minutes) or tinnitus, or if a hearing impairment is suspected.
    • X-ray of the cervical spine is of no benefit.
    • Laboratory tests, as necessary
      • Basic blood count with platelet count (anaemia?), sodium, potassium, TSH (metabolic causes?)
  • Consultations
    • On case by case basis, depending on patient history and physical status
      • Many cases can be managed within primary care without secondary care consultation.
      • Depending on the clinical picture, the patient is referred to either an ear specialist, neurologist or cardiologist.

Typical clinical pictures

Benign postural vertigo

  • See Benign Paroxysmal Positional Vertigo (Bppv)
  • The dizziness spell often begins in the morning or during the night.
  • Typically occurs as the patient takes a recumbent position or turns in the bed a couple of seconds after the change in position. A new change in position will cause a milder spell that usually subsides in about one minute if the head is kept in place.
  • The cause is most often in the posterior semicircular canal. A spell and associated nystagmus can often be provoked during the patient visit by tilting the patient into recumbent position with the head in extension and turned downwards and to the side (Dix-Hallpike test Benign Paroxysmal Positional Vertigo (Bppv)).
  • Horizontal (often partially rotatory) nystagmus may often be observed during the spell.
  • In 90% of the patients spells usually subside within 3 months, but relapses may occur.

Vestibular neuronitis (idiopathic acute vestibular dysfunction)

  • Inflammation of a part of the vestibular nerve; the exact cause is unknown.
  • Rapid onset, violent rotatory vertigo and nausea
  • No hearing impairment, tinnitus or locking of the ear
  • Pathological head jerk test (see above)
  • Spontaneous horizontal rotatory nystagmus towards the healthy ear
  • No other neurological symptoms
  • Severe vertigo usually alleviates in 1-2 weeks. Mild difficulty with balance lasts longer.
  • The attack usually does not recur.

Ménière's disease

  • See Ménière's Disease
  • Symptom triad: spells of rotatory vertigo and nausea, tinnitus, sensorineural hearing impairment
  • Attacks last 2-5 h (20 min-48 h).
  • In the initial phase most attacks are unilateral.
  • Often a sensation of pressure in the ear
  • The initial transient loss of hearing is later followed by a permanent hearing impairment, most often beginning with the lower frequencies. Differentiation of speech diminishes.

Hyperventilation (panic-related vertigo)

  • See Hyperventilation
  • Usually affects younger people and presents either as continuous non-rotatory vertigo or is related to circumstances (queues, shops, theatre). Diagnosis can be made after organic causes have been excluded with sufficient certainty.
  • No abnormal findings on clinical examination; rotatory vertigo or nystagmus cannot be provoked.

Vertigo of cervical origin

  • The sense of movement and position in the cervical region is impaired.
  • Caused by muscle tension and/or the cervical syndrome which is associated with clear nerve root symptoms in the cervical region.
  • Findings are either taut neck and shoulder musculature (tenderness not necessarily found on palpation) or a positive compression test (see Neck and Shoulder Pain).
  • Nystagmus is not found.

Vertigo related to the ageing process in the elderly

  • Often evolves as the result of a combination of several factors like weakening of sensory perception (sight, hearing, taction), weakening of the control of blood circulation and blood pressure, as well as medication; see Falls of the Elderly.

Vertigo caused by medication and alcohol

  • Drugs causing orthostatic hypotension (drugs for hypertension and Parkinson's disease, tricyclic antidepressants, phenothiazines)
  • Anticonvulsants: carbamazepine and phenytoin can cause cerebellar vertigo accompanied by ataxia and nystagmus.
  • Benzodiazepines
  • Alcohol causes
    • cerebellar degeneration in chronic use: vertigo, coordination difficulties, ataxia and tremor
    • polyneuropathy that weakens the sense of position and causes impairment of balance.

Disorders of the cerebral circulation

  • See Transient Ischaemic Attack (Tia) Cerebral Infarction (Ischaemic Stroke) Intracerebral Haemorrhage.
  • TIA, cerebral infarction or intracerebral haemorrhage particularly in the cerebellar and brain stem areas can cause vertigo.
  • Also other CNS symptoms besides vertigo can be found (e.g., diplopia, dysarthria, motor or sensory paralysis symptoms in the extremities, coordination disturbances).
  • Legs suddenly give way (drop attack, that may be a symptom of vertebrobasilar TIA, sometimes also seen in Ménière's disease)
  • The risk factors of stroke (hypertension, atherosclerosis, diabetes, among others) increase both the likehood of the diagnosis and the risk of reccurrence.

Vestibular schwannoma (acoustic neurinoma)

  • Benign, slowly progressing tumour of the vestibulocochlear nerve
  • Gradually progressive unilateral hearing impairment is the most common symptom.
  • Sometimes tinnitus
  • Sometimes difficulties in balance, more rarely rotatory vertigo

Multiple sclerosis

  • See Multiple Sclerosis (Ms).
  • The initial symptoms may include a feeling of dizziness and uncertainty in walking.
  • Other neurological symptoms and findings lead to the diagnosis.

Vertigo of cardiac origin

  • In orthostatic hypotension, the symptoms are worst in the morning and after a meal.
  • Arrhythmias and conduction disorders may be accompanied by attacks of vertigo (non-rotatory type) and collapses.
  • Vertigo may be related to physical exertion.

Treatment Betahistine for Ménière's Disease and Vertigo, Epley Manouvere for Benign Paroxysmal Positional Vertigo, Intratympanic Gentamicin for Ménière's Disease, Vestibular Rehabilitation for Unilateral Peripheral Vestibular Dysfunction

  • Acute vertigo possibly accompanied by vomiting: prochlorperazine in tablet or suppository form or metoclopramide in tablet form, and, if needed, intravenous rehydration
  • Postural vertigo: positional treatment for repositioning of the canaliths, no medication
    • Positional treatment is equally effective in older and younger age groups.
  • In the acute stage of vestibular neuronitis, a course of glucocorticoids can be prescribed even if there is no definitive evidence of effectiveness Corticosteroids for the Treatment of Vestibular Neuritis; e.g. methylprednisolone 64 mg once daily for 5 days, then 32 mg once daily for 5 days.
  • Other otogenic or undefined vertigo: betahistine Betahistine for Ménière's Disease and Vertigo is used in Ménière's disease
  • Neurological disorders: the recurrence risk of cerebral circulation disorders can be influenced by appropriate secondary prevention.
  • Cervical origin: self-stretching (find out about locally available patient education materials), increased physical activity, physiotherapy, acupuncture; possibly a tricyclic antidepressant as drug treatment
  • Panic attack: SSRI antidepressants are first-line treatments Anxiety Disorder.
  • All patients with recurrent vertigo: a training programme to improve control of balance
    • The vicious circle of worsening symptoms must be broken: poor balance leads to minimal mobility and the lack of exercise again deteriorates balance further.

    References

    • Kattah JC, Talkad AV, Wang DZ, et al. HINTS to diagnose stroke in the acute vestibular syndrome: three-step bedside oculomotor examination more sensitive than early MRI diffusion-weighted imaging. Stroke 2009;40(11):3504-10. [PubMed]
    • Dommaraju S, Perera E. An approach to vertigo in general practice. Aust Fam Physician 2016;45(4):190-4. [PubMed]
    • Ranalli P. An Overview of Central Vertigo Disorders. Adv Otorhinolaryngol 2019;82():127-133. [PubMed]
    • Omron R. Peripheral Vertigo. Emerg Med Clin North Am 2019;37(1):11-28. [PubMed]
    • Laurent G, Vereeck L, Verbecque E et al. Effect of age on treatment outcomes in benign paroxysmal positional vertigo: A systematic review. J Am Geriatr Soc 2021;():. [PubMed]