Vertigo

Vertigo is a type of dizziness and involves a false sensation that oneself or the surroundings are moving or spinning, usually accompanied by nausea and loss of balance. Causes of vertigo are often differentiated into:

• Central (cerebral cortex, cerebellum, brainstem), e.g. cerebrovascular disease, migraine, multiple sclerosis, acoustic neuroma, diplopia, alcohol intoxication.
• Peripheral (vestibular labyrinth, semicircular canals or vestibular nerve), e.g. viral labyrinthitis, vestibular neuritis, benign paroxysmal positional vertigo (BPPV), Ménière's disease, motion sickness, ototoxicity (e.g. gentamicin), Herpes zoster (Ramsay Hunt syndrome)

• Viral labyrinthitis.
• Vestibular neuritis (often misdiagnosed as labyrinthitis):
  • Recurrent vertigo attacks lasting hours or days.
  • Followed by dysequilibrium, while central compensation occurs (anxiety may impede central compensation).
  • A preceding viral illness is common.
  • No tinnitus; hearing is not affected.
• Benign paroxysmal positional vertigo:
  • Vertigo associated with head turning or rolling over in bed.
  • Often accompanied by nausea and vomiting.
  • Attacks of vertigo occur in clusters lasting for brief periods of time.
  • There may be a history of head injury.
  • No tinnitus; hearing not affected.
  • Tends to resolve spontaneously after several weeks or months, but some patients experience recurrences months or years later.¹
• Vertebrobasilar ischaemia.
• Eustachian tube dysfunction (causes mild vertigo).
• Ménière's disease:
  • Triad of vertigo, tinnitus, and hearing loss, often associated with a pressure sensation in affected ear.
  • Attacks last from 1 to 24 hours but are often followed by persistent dysequilibrium.
  • Tinnitus is present and often worsens over time.
  • Hearing loss comes and goes at first but is eventually permanent.
• Chronic otitis media.
• Drugs: salicylates, quinine, aminoglycosides.
• Vestibular migraine.
• Epilepsy: likely diagnosis if vertigo is associated with loss of consciousness.
• Acoustic neuroma: may cause mild vertigo, but associated with unilateral sensorineural deafness and tinnitus.
• Nasopharyngeal carcinoma.
• Neurological: brain stem cerebrovascular accident, multiple sclerosis, syringobulbia, cerebellar tumours.
• Post head injury.

• Studies show that about a third of cases of dizziness are vertigo.
• Vast majority of cases seen in primary care are viral, benign positional vertigo or Ménière's disease.
• Prevalence estimates for vertigo are 4.9%, with migrainous vertigo 0.89%, and benign paroxysmal positional vertigo 1.6%. A recently reported prevalence of Ménière's disease of 0.51% is much higher than previous estimates.²

Complaints of dizzy spells are very common and are used by patients to describe many different sensations. The key to making a diagnosis is to find out exactly what the patient means by dizzy and then decide whether or not this represents vertigo. With a clear description of vertigo, the precipitants and time course (onset, frequency, and duration of attacks) are often diagnostic.

• Associated nausea and vomiting suggest a peripheral rather than central cause.³
• Vertigo of central neurological origin is uncommon and less likely to be horizontal or rotatory.
• Nystagmus is common in acute vertigo.
• Hallpike's manoeuvre can be used to confirm benign paroxysmal positional vertigo:¹
  • The patient sits on a flat bed. The examiner then holds the patient's head between the examiner's two hands.
  • The patient then lies back quickly, with the head not supported by the couch and so that the head lies 30 degrees below the horizontal. At the same time the head is rotated 30 degrees towards the examiner. The patient keeps their eyes open.
  • In benign positional vertigo, after about ten seconds, vertigo and rotatory nystagmus towards the affected (now lowest) ear occur for several seconds and then resolve.
  • The vertigo and nystagmus are not then reproducible for the next ten to fifteen minutes.
• Features suggesting a central cause include:
  • Persistent, worsening vertigo.
  • Atypical non-peripheral vertigo, e.g. vertical movement.
  • Severe headache, especially early in the morning.
  • Diplopia.
  • Persistent nystagmus.
  • Cranial nerve palsies.
  • Dysarthria, ataxia, or other cerebellar signs.
  • Papilloedema.

• Dizziness associated with postural hypotension.
• Dysequilibrium, which occurs when the brain receives inadequate information about the body's position from the somatosensory, visual, and vestibular systems, may result from peripheral neuropathy, eye disease, or peripheral vestibular disorders.
• Presyncope is caused by reduced cerebral perfusion caused by cardiovascular disorders or anaemia.
• Lightheadedness is non-specific and hard to diagnose; it may result from panic attacks with hyperventilation.

• No investigations are likely to be performed in primary care.
• Secondary care investigations include:
  • Audiometry for cochlear function.
  • Vestibular function: Electronystagmography, calorimetry and brainstem-evoked responses.
  • Possible neurological cause: CT or MRI.
  • EEG: epilepsy.
  • Lumbar puncture: possible multiple sclerosis.
  • Syphilis serology.

For specific treatment of the various conditions see individual articles.

• Explanation and reassurance are important as anxiety exacerbates vertigo. Persistent dysequilibrium should be overcome by central adaptation, but anxiety may prevent this.
• Drugs that sedate the vestibular-brainstem axis, such as prochlorperazine, relieve symptoms but should not be used on a prolonged basis for any cause of vertigo as they prevent central compensation.⁴ See separate article Treatment of Nausea and Vertigo.
• Betahistine may improve perfusion of the labyrinth and is used prophylactically in Ménière's disease. There is little evidence of its efficacy.⁵
• There is evidence to support the efficacy of vestibular rehabilitation programs for unilateral peripheral vestibular disorder; a simple programme including patient education and home based exercises can be sufficient.⁶
• Balance rehabilitation is important and beneficial in elderly people, in whom dizziness is invariably multifactorial.
• A recent Cochrane review confirmed the efficacy of the Epley manoeuvre⁷ in treating benign paroxysmal positional vertigo.⁸ See under Internet and further reading below for a description and diagrams showing the Epley manoeuvre.
• The Cawthorne-Cooksey and other vestibular rehabilitation exercises promote central compensation and help resolve persistent dysequilibrium. Dysequilibrium due to Ménière's disease or benign paroxysmal positional vertigo may not respond. See under Internet and further reading below for a description of Cawthorne-Cooksey exercises.
• Referral to an ENT specialist is indicated if there is associated hearing loss or recurrent or persistent vertigo with peripheral vestibular characteristics or if otoscopy findings are abnormal.
• Ménière's disease: labyrinthectomy and cochlear implants have been used. More recently, intratympanic gentamicin application has also been used successfully for Ménière's disease.⁹

• Increased risk of falls, especially in the elderly.
• Vertigo may confine people to their home, making them fearful or depressed.

• Follow-up studies have shown benign paroxysmal positional vertigo recurrence rates of 50% at 5 years and a persistence of dizziness related to anxiety in almost a third of patients 1 year after vestibular neuritis.²