Vertigo

Background

• Sensation of the room (or themselves) spinning or moving

• Must distinguish from lightheadedness, presyncope, orthostasis, and disequilibrium (unsteady on feet) via history

• Distinguishing between central vs peripheral pattern is useful for workup and management

• Central pattern: typically less sudden onset (unless stroke), continuous symptoms independent of position, no/limited hearing loss, and may have other FND

• Peripheral pattern: typically sudden onset, positional with severe nausea, tinnitus, or decreased hearing, no other FND

• Causes best differentiated based on chronicity and triggers rather than description of symptoms

Etiologies:

• BPPV: loose otoliths; short duration (<1min), very positional, nystagmus is horizontal and torsional, towards affected ear with posterior canal being most commonly involved; treat with particle repositioning maneuvers

• Vestibular neuritis/labyrinthitis: typically follows URI or ear infection with unidirectional nystagmus away from affected ear; self-limited, but if severe/prolonged can treat with steroids

• Meniere’s disease: Vertigo, tinnitus, and low range frequency hearing loss. Gradually progressive. Treated with diuretics, salt restriction, Meclizine, and sometimes surgery or intratympanic injections

• Endolymphatic leak: Usually following trauma or concussive blasts. Requires ENT evaluation and management. Classically a loud sound will cause vertigo and nystagmus

• Vertiginous migraine: episodic vertigo associated with headaches; usual migraine triggers, may have aura; often positive family history of migraine

• Stroke: Typically due to brainstem or cerebellar infarct; sudden onset; rare cause of isolated vertigo; ask about vascular RF. Also consider vertebral dissection or vertebrobasilar TIA

• Drug-induced: assess recent changes in medications; includes codeine, aminoglycosides, macrolides, sulfamethoxazole, NSAIDs, prednisone, anti-malarials, diuretics, beta-blockers, alpha-antagonists, lithium, antipsychotics

• Other causes: demyelinating disease (MS), epileptic vertigo (focal seizures), Ramsay-Hunt syndrome (Herpes zoster oticus), cerebellopontine angle tumors (often little vertigo as CNS compensates as tumor slowly grows)

Evaluation and Management

• Careful exam of vertigo will be more helpful than random scans, but pt has to be symptomatic for exam to mean anything

  • HINTS Battery – Head Impulse test, Nystagmus pattern, Test of Skew
  • Only useful if pt is currently symptomatic
  • Central pattern: no corrective saccade, multidirectional nystagmus, skew present
  • Peripheral pattern: corrective saccade, unidirectional nystagmus, no skew present
  • Dix-Hallpike Test
  • Cerebellar testing: Finger nose finger (FNF), heel knee shin (HKS), mirroring, gait o
  • Outpt Vestibular function testing with ENT

• Central patterns will need head and vessel imaging looking for vertebral dissection or basilar clots

  • Often, central vertigo is due to centrally acting medications

• Peripheral causes are varied and often require evaluation by ENT as an outpt

• Treatment with anticholinergics like meclizine or scopolamine is often helpful; antiemetics if significant nausea; and benzodiazepines for refractory acute attacks

• Vestibular therapy is also very beneficial