section name header

Information ⬇

Editors

TimoAtula
SariAtula
KyöstiLaitakari
MikaelOjala

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 it may be caused by a disorder of the cerebral circulation (TIA, stroke). In such a case the patient is referred to hospital examinations on an emergency basis when less than 2 weeks have elapsed since the symptom start.
  • Further examinations are indicated in recurring or prolonged rotatory vertigo as well as in cases involving impairment of hearing or neurological symptoms or findings in addition to possible nystagmus.
  • Vertigo-inducing medication is checked and its dosage reduced if possible.
  • Usually it is not worthwhile to treat symptomatic vertigo with drugs. Antiemetic medication is indicated in acute vertigo if the patient vomits.

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
    • orthostatic hypotension (when standing up; often associated with low blood pressure levels and occurs especially in the elderly)
    • vestibular neuronitis (acute-onset, prolonged vestibular dysfunction)
    • Ménière's disease
    • circulatory disturbances of the cerebellum and brain stem (when associated with other symptoms) Cerebral Infarction (Ischaemic Stroke)
    • cerebellar atrophy (usually associated with long-term excessive use of alcohol)
    • vertigo related to the ageing process in the elderly (brain, eyes, organs of balance, peripheral sense of posture, orthostatism)
    • panic attack (hyperventilation).
  • The cause remains unexplained in about 10% of cases despite extensive examinations.
  • Vertigo induced by excessive medication is common.

Case history

  • A thorough interview is the most important part of diagnostics.
    • Does the patient really have vertigo or is there merely a problem with balance? The patients often cannot differentiate between these.
    • Balance problems can be caused by e.g. diseases of the peripheral nervous system (polyneuropathy) or of the cerebellum.
    • Is the vertigo rotary or does it create a sense of falling? In the latter case, is there a certain direction to the falling sensation?
      • 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.
    • The association of vertigo with various situations (change in posture, head rotation, physical exertion)
      • Vertigo associated with changes in posture or rotation of the head is benign postural vertigo.
      • Vertigo associated with physical exertion may be a vagal reflex or a sign of possible cardiac arrhythmia.
    • Paroxysmal nature
      • Postural vertigo and TIA: short duration, often a few minutes only
      • An attack of Ménière's disease lasts tens of minutes.
      • Vestibular neuronitis or cerebellar infarction can cause violent vertigo that may last for even more than a week.
    • Symptoms of tension neck include ”boat deck vertigo”, a momentary need to take a sidestep, headache, difficulties with visual acuity, nausea, and tenderness of the scalp.
    • Accompanying symptoms indicating ear or CNS involvement
      • Hearing impairment, tinnitus or ear pain
        • Ménière's disease, acoustic neurinoma or otitis media
      • Paralytic symptoms, coordination disturbances, diplopia, difficulty producing speech
        • Disorder of the cerebral circulation - infarction or haemorrhage
    • Does the patient have palpitations or chest discomfort?
      • May suggest cardiac arrhythmia.
  • Revision of medication

Clinical examination

  • Observation of nystagmus (most reliably with Frenzel goggles that magnify the eyes) in various positions, especially during the Dix-Hallpike test .
    • Occurs in vestibular neuronitis (horizontal), Ménière's disease and postural vertigo (horizontal and partially rotatory nystagmus usually caused by a disturbance of the posterior semicircular canal).
    • Rarely occurring vertical nystagmus usually indicates a disorder in the brain stem area, but a vertical component may sometimes also be observed in horizontal nystagmus associated with postural 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.
  • 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 (Unterberger stepping test) evaluate objectively the degree of disturbance in balance.
    • Coordination tests
    • Cranial nerves, muscle strengths, tendon reflexes
    • Tympanic membranes (otitis, labyrinthine irritation)
    • Tuning fork tests (pictures Weber Test Rinne Test) to define possible hearing impairment
    • An audiogram is indicated if the patient has persistent spinning dizziness (tens of minutes), tinnitus, or if a hearing impairment is suspected.
    • Blood pressure sitting and standing, orthostatism test if needed
    • Auscultation of the heart and possibly Holter monitoring (possible cardiac arrhythmias)

Typical signs and symptoms

Benign postural vertigo

  • See
  • The dizziness spell often begins in the morning or during the night.
  • Typically exacerbated 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 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).
  • 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)

  • The exact cause is unknown; inflammation of the inner ear is suspected.
  • Rapid onset, violent rotatory vertigo and nausea
  • Normal (symmetrical) audiogram
  • Pathological head jerk test
  • Spontaneous horizontal rotatory nystagmus towards the healthy ear
  • No other neurological symptoms
  • Severe vertigo passes in 1-2 weeks. Mild difficulty with balance lasts longer.
  • The attack usually does not recur.

Ménière's disease

  • See
  • Symptom triad: spells of rotatory vertigo and nausea, tinnitus, variable 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 ears
  • The initial transient loss of hearing is later followed by a permanent hearing impairment of inner ear type beginning with the lower frequencies. Differentiation of speech diminishes.

Hyperventilation (panic-related vertigo)

  • See
  • 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 ).
  • 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, blood circulation, control of blood pressure and medication; see .

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) 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 major symptom.
  • Sometimes tinnitus
  • Feeling of uncertainty in walking, 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.

Further investigations

  • Examinations in primary health care
    • ECG, laboratory tests and Holter monitoring according to the suspected aetiology
    • Audiogram if an ear disorder is suspected
    • A cervical x-ray is not useful.
  • Specialist examinations
    • Brain MRI if a cause of cerebellar or brain stem origin is suspected
    • Non-urgent brain stem MRI in suspicion of vestibular schwannoma (acoustic neurinoma)
  • Consultations
    • Case-by-case on the basis of the case history and status. Majority of cases can be managed in primary health care without specialist consultation.
    • Depending on the observed signs and symptoms, the patient may be referred to an ENT specialist, neurologist or cardiologist.

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)
  • Postural vertigo: positional treatment for repositioning of the canaliths, no medication
  • 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 only
  • Neurological disorders: the recurrence risk of cerebral circulation disorders can be influenced by appropriate secondary prevention.
  • Cervical origin: self-stretching, increased physical activity, physiotherapy, acupuncture; possibly a tricyclic antidepressant as drug treatment
  • Panic attack: SSRI antidepressants are first-line treatments.
  • 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.

Related Resources ⬆

Related resources