VERTIGO

VERTIGO - Michele Matthews, PharmD; Kristy Kedian, DO
BASICS
DESCRIPTION
• Sensation of movement when no movement is actually occurring. Results from peripheral or central causes or, in some instances, may be induced by medications or anxiety disorders.
• System(s) Affected: Nervous
• Synonym(s): Dizziness; Acute vestibular neuronitis; Labyrinthitis; Benign paroxysmal positional vertigo (BPPV)
GENERAL PREVENTION
• Precautions to avoid injuries from falls that may occur secondary to imbalance
• If due to motion sickness, pretreatment with anticholinergics such as scopolamine
EPIDEMIOLOGY
• Women are more likely to experience central causes, particularly vertiginous migraine.
• Patients who are elderly and have risk factors for cerebrovascular disease (CVD) are more likely to experience central causes.
Incidence
Accounts for 54% of cases of dizziness reported in primary care:
• >90% of these patients are diagnosed with peripheral causes, such as BPPV.
Prevalence
Ranges from 5-10% within the general population
RISK FACTORS
• History of migraines
• History of CVD or risk factors for CVD
• Use of ototoxic medications
• Trauma or barotrauma
• Perilymphatic fistula
• Heavy weightbearing
• Psychosocial stress
• Exposure to toxins
Genetics
Family history of CVD or migraines may indicate higher risk of central causes.
PATHOPHYSIOLOGY
Caused by dysfunction of the rotational velocity sensors of the inner ear. Results in asymmetrical central processing. Related to the combination of sensory disturbance of motion and the malfunction of the central vestibular apparatus.
ETIOLOGY
• Peripheral causes
- Acute labyrinthitis, acute vestibular neuronitis, BPPV, cholesteatoma, herpes zoster oticus, Meniere disease, otosclerosis
• Central causes
- Cerebellar tumor, CVD, migraine, multiple sclerosis
• Other causes
- Cervical, drug-induced, psychological
ASSOCIATED CONDITIONS
See "Etiology."


DIAGNOSIS
SIGNS AND SYMPTOMS
• Dizziness
• Rotary illusions
• Nystagmus
• Nausea and vomiting
• Hearing loss
• Pallor
• Diaphoresis
• Pain
• Neurologic symptoms (i.e., ataxia)
History
• Determine if true vertigo exists versus other causes of dizziness by asking the patient if they feel lightheaded or if they see the world spinning around them during a dizzy spell. (1)
- Affirmative answer to spinning is indicative of true vertigo
• Distinguish between peripheral and central causes.
- Timing and duration
 Seconds to minutes: Peripheral
 Minutes to hours: Peripheral or central
 Days: Peripheral or central
 Weeks: Central or psychological
- Provoking factors
 Changes in head position: Peripheral or central
 Spontaneous episodes: Peripheral or central
 Recent upper viral respiratory infection: Peripheral
 Stress: Central or psychological
 Immunosuppression: Peripheral
 Changes in ear pressure: Peripheral
- Associated symptoms
 Rotary illusions with nausea and vomiting: Peripheral
 Horizontal and rotational nystagmus: Peripheral
 Horizontal, vertical, or rotational nystagmus: Central
 Hearing loss: Peripheral
 Neurologic symptoms: Central
• Obtain medical and medication history
- Recent use of ototoxic medications
- History of CVD or risk factors for CVD
Physical Exam
• Neurologic (1)
- Cranial nerves for signs of palsies, nystagmus
- Balance
 Peripheral: Mild to moderate, able to walk
 Central: Severe, unable to walk
- Dix-Hallpike maneuver (PPV = 83%, NPV = 52%)
 If induced symptoms subside after repeated maneuvers, consider peripheral causes.
 If induced symptoms do not subside, consider central causes.
• Head and neck (1)
- Tympanic membranes
 Vesicles: Herpes zoster oticus
 Cholesteatoma
• Cardiovascular (1)
- Orthostatic changes in BP: Dehydration or autonomic dysfunction
TESTS
Lab
Audiometry if acoustic neuroma or Meniere disease is suspected
Imaging
Consider MRI in the presence of neurologic symptoms, risk factors for CVD, or progressive unilateral hearing loss.
DIFFERENTIAL DIAGNOSIS
• Acoustic neuroma
• Anxiety disorder
• BPPV
• Cerebellar degeneration
• Cerebellar tumor
• Labyrinthine concussion
• Labyrinthitis
• Meniere disease
• Multiple sclerosis
• Perilymphatic fistula
• Syphilis
• Vascular ischemia
• Vertiginous migraine
• Vestibular neuronitis
• Vestibular ototoxicity
TREATMENT
• Epley maneuver for BPPV (2)[A]
• Modified Epley maneuver for BPPV (3)[B]
• Vestibular exercises for acute vestibular neuronitis (3)[B]
• Low-salt diet and diuretics for Meniere disease (3)[B]
• Migraine prophylaxis, migraine abortive medications, and vestibular exercises for vertiginous migraines (3)[B]
• Selective serotonin reuptake inhibitors (SSRIs) when associated with anxiety disorders (3)[B]
• Vestibular suppressant medications for symptom relief in acute vestibular neuronitis (3,4)[C]
GENERAL MEASURES
• Provide an explanation and offer assurance to avoid anxiety that may exacerbate vertigo.
• Treatments depend on cause
- BPPV: Epley maneuver or modified Epley maneuver (2)[A] (see "Special Therapy")
- Vestibular neuronitis and labyrinthitis
 Vestibular suppressant medications (3,4)[C] (see "Medications")
 Vestibular rehabilitation exercises (3)[B] (see "Physical Therapy")
- Meniere disease:
 Low-salt diet (1-2 g/d) (3)[B]
 Diuretics such as hydrochlorothiazide (3)[B]
- Vascular ischemia
 Prevention of future events through blood pressure reduction, lipid lowering, smoking cessation, antiplatelet therapy, and anticoagulation if necessary
- Vertiginous migraines
 Dietary and lifestyle modifications, vestibular rehabilitation exercises, prophylactic and migraine abortive medications (3)[B]
- Drug-induced vertigo
 Discontinue causative agent
- Psychological
 SSRIs (3)[B]
Diet
• Restricted salt intake for Meniere disease
• Dietary modifications for vertiginous migraine
SPECIAL THERAPY
Epley maneuver or modified Epley maneuver for BPPV to displace calcium deposits in the semicircular canals (2)[A]
• Improves symptoms and converts patient from positive to negative Dix-Hallpike maneuver
• Contraindications: Carotid stenosis, unstable cardiac disease, severe neck disease
Physical Therapy
Vestibular rehabilitation exercises (3)[B]
• Ball toss
• Lying-to-standing
• Target-change
• Thumb-tracking
• Tightrope
• Walking turns
MEDICATION (DRUGS)
First Line
• Meclizine (Antivert): 12.5-50 mg PO q4-8h (3,4)[C]
• Dimenhydrinate (Dramamine): 25-100 mg PO, IM, or IV q4-8h (3,4)[C]
- Precautions: Concomitant use of CNS depressants, prostatic hyperplasia, glaucoma
- Adverse effects: Sedation, xerostomia
- Interactions: CNS depressants
• Prochlorperazine (Compazine): 5-10 mg PO or IM q6-8h; 25 mg rectally q12h; 5-10 mg by slow IV over 2 minutes (3,4)[C]
- Contraindications: Blood dyscrasias, age 2 years, severe hypotension
- Precautions: Children with acute illness; glaucoma, history of breast cancer, impaired cardiovascular function, pregnancy, prostatic hyperplasia
- Adverse effects: Sedation, xerostomia, hypotension, extrapyramidal effects
- Interactions: Phenothiazines, tricyclic antidepressants
• Metoclopramide (Reglan): 5-10 mg PO q6h, 5-10 mg slow IV q6h
- Contraindications: Concomitant use of drugs with extrapyramidal effects, seizure disorders
- Precautions: History of depression, Parkinson disease, hypertension
- Adverse effects: Sedation, fluid retention, constipation
- Interactions: Linezolid, cyclosporine, digoxin, levodopa
• Benzodiazepines (3,4)[C]
- Diazepam (Valium): 2-10 mg PO or IV q4-8h
- Lorazepam (Ativan): 0.5-2 mg PO, IM, or IV q4-8h
 Contraindications: Glaucoma, age 6 months
 Precautions: Concomitant use of CNS depressants, hepatic insufficiency, pregnancy
 Adverse effects: Sedation, respiratory depression, hypotension
 Interactions: CNS depressants
ALERT
Geriatric Considerations
Use vestibular suppressant medications with caution
- Increased risk of falls
- Urinary retention
Pregnancy Considerations
Meclizine and dimenhydrinate are Pregnancy Category B
FOLLOW-UP
DISPOSITION
Issues for Referral
Consider referral to otolaryngologist, ENT specialist, or neurologist if patient requires further care.
PROGNOSIS
Depends on diagnosis and response to treatment
COMPLICATIONS
• Anxiety
• Depression
• Disability
• Injuries from falls
PATIENT MONITORING
After 1-2 weeks, assess for
• Recurrence of symptoms
• New-onset symptoms
• Medication-related adverse effects
• Relief from vestibular rehabilitation exercises
REFERENCES
1. Labuguen RH. Initial evaluation of vertigo. Am Fam Physician. 2006;73:244-251.
2. Hilton M, Pinder D. The Epley (canalith repositioning) maneuver for benign paroxysmal positional vertigo. Cochrane Database Syst Rev. 2004;(3):CD003162.
3. Swartz R, Longwell P. Treatment of vertigo. Am Fam Physician. 2005;71:1115-1122.
4. Hain TC, Uddin M. Pharmacological treatment of vertigo. CNS Drugs. 2003;(2):85-100.
MISCELLANEOUS
See also BPPV, Meniere disease, Motion sickness