Vertigo

Vertigo is a false sensation of movement of the self or the environment, usually rotation.

Anatomy and physiology. The labyrinth (semicircular canals and otoliths), vestibular nerve, vestibular nuclei, brainstem and cerebellum process head motion. An asymmetry in tonic input produces vertigo with nystagmus and nausea.

Classification by timing and trigger (the vestibular syndromes).

• Acute vestibular syndrome: continuous vertigo lasting days with nausea, nystagmus and gait instability (vestibular neuritis, labyrinthitis, posterior circulation stroke).
• Triggered episodic vestibular syndrome: brief vertigo lasting under 1 minute provoked by head position change (benign paroxysmal positional vertigo, central positional vertigo).
• Spontaneous episodic vestibular syndrome: attacks lasting minutes to hours without trigger (Meniere disease, vestibular migraine, transient ischaemic attack).
• Chronic vestibular syndrome: weeks to months (bilateral vestibulopathy, cerebellar disease, persistent postural perceptual dizziness).

Key distinctions. Peripheral nystagmus is unidirectional, horizontal with a torsional component, suppressed by fixation, and obeys Alexander law. Central nystagmus can be vertical, direction changing, not suppressed by fixation, and accompanied by neurological signs.

History. Duration of each episode, trigger (rolling over in bed, looking up, standing), continuous or episodic, hearing loss, tinnitus, aural fullness, headache, photophobia, neck pain or trauma, preceding viral illness, neurological symptoms (diplopia, dysarthria, dysphagia, limb weakness, facial numbness), vascular risk factors, and falls.

Drug history. Aminoglycosides (including topical gentamicin), loop diuretics, platinum agents, anticonvulsants, sedatives, antihypertensives, alcohol.

Examination.

• Spontaneous nystagmus in primary gaze and on lateral gaze, with and without fixation.
• Head impulse test (corrective saccade on thrust toward the affected side indicates peripheral loss).
• Test of skew (vertical misalignment on alternate cover indicates central cause).
• HINTS plus examination (head impulse, nystagmus, test of skew, and hearing): a normal head impulse, direction changing nystagmus or skew deviation indicates a central cause. Use it only in acute vestibular syndrome with ongoing spontaneous nystagmus, and only by trained examiners.
• Dix Hallpike test (posterior canal) and supine roll test (horizontal canal).
• Gait, truncal ataxia (inability to sit unsupported suggests central), limb coordination, cranial nerves, hearing, and blood pressure.

Red flags

• Any neurological sign, severe headache or neck pain
• Inability to walk or sit unaided
• Central pattern nystagmus, skew deviation, or normal head impulse in acute continuous vertigo
• Vascular risk factors with acute vertigo
• New sudden hearing loss
• Recent head or neck trauma (dissection)
• Fever or ear infection with vertigo

Special groups. Older adults: stroke more likely. Pregnancy: benign paroxysmal positional vertigo and vestibular migraine. Children: vestibular migraine, benign paroxysmal vertigo of childhood.

Peripheral

• Benign paroxysmal positional vertigo (posterior, horizontal, anterior canal)
• Vestibular neuritis and labyrinthitis
• Meniere disease
• Ramsay Hunt syndrome
• Perilymph fistula, superior semicircular canal dehiscence
• Otitis media with labyrinthine complications, cholesteatoma
• Vestibular schwannoma
• Ototoxicity, bilateral vestibulopathy
• Temporal bone fracture, barotrauma

Central

• Posterior circulation stroke and transient ischaemic attack, vertebral artery dissection
• Cerebellar infarction and haemorrhage
• Vestibular migraine
• Multiple sclerosis, brainstem lesion
• Posterior fossa tumour, Chiari malformation
• Wernicke encephalopathy
• Central positional vertigo (cerebellar lesions)
• Drug toxicity (anticonvulsants, alcohol)

Systemic and other

• Orthostatic hypotension, arrhythmia, anaemia
• Hypoglycaemia
• Cervicogenic dizziness
• Persistent postural perceptual dizziness, panic disorder

Reasoning. Classify the syndrome by timing and trigger, perform the matching bedside test, and decide on imaging from central features and vascular risk.

First line. Blood pressure (lying and standing), capillary glucose, pulse rhythm, ECG, otoscopy, hearing tests, Dix Hallpike and head impulse tests.

Benign paroxysmal positional vertigo. Dix Hallpike test: latent onset of torsional upbeating nystagmus with vertigo lasting under 1 minute that fatigues, indicates posterior canal disease. No imaging is needed for a typical case.

Imaging. MRI brain with diffusion weighted imaging and vessel imaging (MR or CT angiography) for acute vestibular syndrome with central signs or vascular risk, remembering that CT is insensitive for posterior fossa infarction, and that early MRI can be falsely normal in the first 24 to 48 hours. MRI of the internal acoustic meatus with gadolinium for asymmetric sensorineural loss, or progressive unilateral vestibular loss. CT temporal bone for trauma or suspected cholesteatoma.

Audiovestibular tests. Pure tone audiometry for all with hearing symptoms. Videonystagmography, caloric testing and video head impulse testing for chronic or unclear vestibular loss.

Blood tests. Glucose, full blood count, electrolytes, thyroid function, vitamin B12, and others by suspicion.

Meniere disease criteria. At least two spontaneous vertigo episodes lasting 20 minutes to 12 hours, audiometric low to medium frequency sensorineural loss documented on at least one occasion, and fluctuating aural symptoms (hearing, tinnitus, fullness).

Vestibular migraine criteria. At least five episodes of vestibular symptoms lasting 5 minutes to 72 hours, current or past migraine, and migraine features with at least half of episodes.

Limitations. Severity of vertigo does not separate peripheral from central causes. HINTS is reliable only in the hands of trained examiners and in the correct syndrome.

Posterior circulation stroke. Emergency stroke care: alteplase 0.9 mg/kg IV (maximum 90 mg), 10 percent as a bolus over 1 minute and the remainder over 60 minutes, within 4.5 hours when haemorrhage is excluded, or tenecteplase 0.25 mg/kg IV as a single bolus (maximum 25 mg); blood pressure under 185/110 mmHg before and under 180/105 mmHg for 24 hours after thrombolysis; aspirin 300 mg orally daily when thrombolysis is not given; neurosurgical referral for cerebellar infarct or haemorrhage with brainstem compression.

Benign paroxysmal positional vertigo.

• Epley manoeuvre for posterior canal disease (success in most patients after 1 or 2 treatments; repeat at 1 week if symptoms persist). Semont manoeuvre is an alternative. Horizontal canal: Gufoni manoeuvre or barbecue roll.
• Do not give vestibular suppressants routinely. Warn about neck, spine and vascular contraindications to the manoeuvre.

Vestibular neuritis.

• Short course symptomatic treatment: prochlorperazine 5 mg orally every 8 hours (or 12.5 mg IM once) for up to 3 days, or ondansetron 4 mg IV or orally every 8 hours for nausea (maximum 16 mg in a single dose; QT warning). Avoid prolonged use of vestibular suppressants, which delay central compensation.
• Prednisolone 1 mg/kg orally each morning (maximum 60 to 80 mg) for 5 days then tapered over 10 days when started within 72 hours (evidence for benefit is limited).
• Early mobilisation and vestibular rehabilitation exercises.

Meniere disease. Low salt diet (under 2 g sodium daily), avoidance of caffeine and alcohol, betahistine 16 mg orally three times daily (evidence limited), and thiazide diuretic by specialist decision. Acute attack: prochlorperazine 5 mg orally or ondansetron 4 mg. Refractory disease: intratympanic corticosteroid or gentamicin, endolymphatic sac surgery, by ENT.

Vestibular migraine. Trigger avoidance and migraine preventive drugs: propranolol 40 mg orally twice daily increased every 2 weeks to a usual 80 to 160 mg daily (maximum 240 mg daily), or amitriptyline 10 mg at night increased by 10 mg weekly to 25 to 75 mg. Acute attack: antiemetic and, when no contraindication, sumatriptan 50 to 100 mg orally.

Ramsay Hunt syndrome. Valaciclovir 1 g orally three times daily for 7 days with prednisolone 1 mg/kg orally daily (maximum 60 mg) for 7 days then reduced over 7 days, started within 72 hours; adjust valaciclovir to creatinine clearance (30 to 49 mL/min, 1 g every 12 hours; 15 to 29 mL/min, 1 g daily; under 15 mL/min, 500 mg daily).

Other causes. Orthostatic hypotension and arrhythmia: treat the cause. Wernicke encephalopathy: thiamine 500 mg IV every 8 hours for 2 to 3 days before glucose. Ototoxicity: stop the drug when possible. Vestibular schwannoma: ENT or neurosurgical referral. Persistent postural perceptual dizziness: vestibular rehabilitation, cognitive behavioural therapy, and selective serotonin reuptake inhibitor in selected patients (sertraline 25 mg daily increased to 50 mg daily).

Monitoring. Reassess at 1 to 2 weeks. Persistent symptoms beyond 6 weeks need specialist vestibular assessment.

Referral and escalation. Immediate for suspected stroke. ENT or neuro-otology for atypical, recurrent or persistent vertigo, Meniere disease and asymmetric hearing loss. Neurology for suspected vestibular migraine and central causes.

Admission criteria. Suspected central cause, inability to walk, persistent vomiting with dehydration, or concurrent neurological signs.

Discharge and safety netting. Advise on driving restriction during vertigo and falls prevention. Return for new weakness, speech or visual change, severe headache, inability to walk, hearing loss or persistent vomiting.