5/26/2015

VertigoDiagnosisandmanagementinprimarycare|BritishJournalofMedicalPractitioners

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Vertigo Diagnosis and management in primary care

DaljitSinghSuraandStephenNewell
Citethisarticleas:BJMP20103(4):a351
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GeneralInformation
1. Vertigoisthehallucinationofmovementoftheenvironmentaroundthepatient,orofthepatientwithrespectto
theenvironment1.Itisnotafearofheights.
2. Vertigoisnotnecessarilythesameasdizziness
3. Dizzinessisanonspecifictermwhichcanbecategorisedintofourdifferentsubtypesaccordingtosymptoms
describedbythepatients:
a. Vertigo
b. Presyncope:thesenseofimpendingfaint,causedbyareducedtotalcerebralperfusion
c. Lightheadedness:oftendescribedasgiddinessorwooziness2
d. Disequilibrium:afeelingofunsteadinessorimbalancewhenstanding2

ClassificationVertigomaybeclassifiedas:
1. Centralduetoabrainstemorcerebellardisorder
2. PeripheralduetodisordersoftheinnerearortheVestibulocochlear(VIIIth)cranialnerve
Incidence/Prevalence:Mostpatientswhocomplainaboutdizzinessdonothavetruevertigo:
1. 5communitybasedstudiesintodizzinessindicatedthataround30%ofpatientswerefoundtohavevertigo,
risingto56.4%inanolderpopulation3
2. Apostalquestionnairestudywhichexamined2064patients,aged1865,7%describedtruevertigointhe
previousyear3
3. AfulltimeGPcanthereforeexpectbetween1020patientswithvertigoinoneyear3
4. 93%ofprimarycarepatientswithvertigohaveeitherbenignparoxysmalpositionalvertigo(BPPV),acute
vestibularneuronitis,orMnire'sdisease4.TheseconditionsarehighlightedinTable2
CausesAwiderangeofconditionscancausevertigo,andidentifyingwhetherdeafnessorCNSsignsarepresent,can
helpnarrowthedifferentialdiagnosis,asshowninTable1.
Table1Causesofvertigo
Vertigowithdeafness

Vertigowithoutdeafness

Vertigowithintracranialsigns

Mniresdisease

Vestibularneuronitis

Cerebellopontineangletumour

Labyrinthitis

Benignpositionalvertigo

Cerebrovasculardisease:TIA/CVA

Labyrinthinetrauma

Acutevestibulardysfunction

Vertebrobasilarinsufficiencyand
thromboembolism:lateralmedullary
syndromesubclavianstealsyndrome
basilarmigraine

Acousticneuroma

Medicationinducedvertigoe.g.

Braintumour:e.g.ependymoma

aminoglycosides

ormetastasisinthefourthventricle

Acutecochleovestibulardysfunction

Cervicalspondylosis

Migraine

Syphilis(rare)

Followingflexionextensioninjury

Multiplesclerosis

Auraofepilepticattackespecially
temporallobeepilepsy

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Drugse.g.phenytoin,barbiturates

Syringobulbia

Symptoms
1. Vertigomaybeduetocentrallesionsorperipherallesions.Vertigomayalsobepsychogenicoroccurinconditions
whichlimitneckmovement,suchasvertigocausedbycervicalspondylosis,orfollowingawhiplashflexion
extensioninjury.
2. Itisessentialtodeterminewhetherthepatienthasaperipheralorcentralcauseofvertigo1.
3. Informationobtainedfromthehistorythatcanbeusedtomakethisdistinctionincludes1:
a. Thetiminganddurationofthevertigo
b. Provokingorexacerbatingfactors
c. Associatedsymptomssuchas
i. Pain
ii. Nausea
iii. Neurologicalsymptoms
iv. Hearingloss

4. Centralvertigo:
a. Thevertigousuallydevelopsgradually
b. Exceptin:anacutecentralvertigoisprobablyvascularinorigin,e.g.CVA
c. Centrallesionsusuallycauseneurologicalsignsinadditiontothevertigo
d. Auditoryfeaturestendtobeuncommon.
e. Causessevereimbalance
f. Nystagmusispurelyvertical,horizontal,ortorsionalandisnotinhibitedbyfixationofeyesontoanobject

5. Thedurationofvertigoepisodesandassociatedauditorysymptomswillhelptonarrowthedifferentialdiagnosis5.
Thisisillustratedforvariouspathologiesthatcausevertigo,inTable2
Table2Timingofsymptoms
AssociatedAuditory

PeripheralorCentral

Symptoms

Origin

Seconds

No

Peripheral

VestibularNeuronitis

Days

No

Peripheral

Mnire'sDisease

Hours

Yes

Peripheral

PerilymphaticFistula

Seconds

Yes

Peripheral

TransientIschemicAttack

Seconds/Hours

No

Central

VertiginousMigraine

Hours

No

Central

Labyrinthitis

Days

Yes

Peripheral

Stroke

Days

No

Central

AcousticNeuroma

Months

Yes

Peripheral

CerebellarTumour

Months

No

Central

MultipleSclerosis

Months

No

Central

Pathology
BenignParoxysmalPositional
Vertigo

DurationOfEpisode

Itisimportanttodifferentiatevertigofromnonrotatorydizziness(presyncope,disequilibrium,lightheadedness).
Patientscanbeaskedwhethertheyfeltlightheadedorfeltasiftheworldwasspinningaroundduringadizzy
spell3.
6. Importantpointsinthehistory:
a. Onsetspecificprovokingeventssuchasflyingortrauma
b. Duration:

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i. SecondsBenignpositionalvertigo
ii. HoursMnire'sDisease
iii. WeeksLabyrinthitis,Postheadtrauma,Vestibularneuronitis
iv. Yearsmaybepsychogenic
c. AssociatedauditorysymptomsrareinprimaryCNSlesion
d. Otherassociatedsymptoms
i. Nauseaandvomitinginavestibularcause
ii. Neurologicalsymptomssuchasvisualdisturbance,dysarthriainacentrallesion

Physical/signs
1. Examinationofeardrums(Otoscopy/Pneumaticotoscopy)for:
a. Vesicles(RamsayHuntsyndrome)
b. Cholesteatoma
2. TuningforktestsforhearinglossRinne/Webertests
3. Cranialnerveexamination.Cranialnervesshouldbeexaminedforsignsof:
a. Nervepalsies
b. Sensorineuralhearingloss
c. Nystagmus3

4. Hennebert'ssign1
a. Vertigoornystagmuscausedbypushingonthetragusandexternalauditorymeatusoftheaffectedside
b. Indicatesthepresenceofaperilymphaticfistula.
5. Gaittests:
a. Romberg'ssign(notparticularlyusefulinthediagnosisofvertigo1)
b. Heeltotoewalkingtest
c. Unterberger'ssteppingtest1(Thepatientisaskedtowalkonthespotwiththeireyesclosedifthepatient
rotatestoonesidetheyhavelabyrinthlesiononthatside
6. DixHallpikemanoeuvre1
a. Themosthelpfultesttoperformonpatientswithvertigo1
b. IfrotationalnystagmusoccursthenthetestisconsideredpositiveforBPPV.Duringapositivetest,thefast
phaseoftherotatorynystagmusistowardtheaffectedear,whichistheearclosesttotheground.
7. Headimpulsetest/headthrusttest
a. Usefulinrecognizingacutevestibulopathy6
8. Calorictests
a. Coldorwarmwaterorairisirrigatedintotheexternalauditorycanal
b. Notcommonlyused

Investigations/Testingtoconsider:
1. Specialauditorytests
a. AudiometryhelpsestablishthediagnosisofMnire'sdisease

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2. Thehistoryismostimportantandmaygiveaquitegoodindicationofthecauseofvertigo.Generalmedicalcauses
suchasanaemia,hypotensionandhypoglycaemiamaypresentwithdizziness,andthereforeshouldbe
investigated.
3. IffeaturesofCNScausesissuspectedfromthehistoryorexamination:
a. CT/MRIBrainimagingasappropriate

Treatment
1. Treatmentshouldideallyaimatthecauseofthevertigo7:
a. Medicalmanagementasdescribedbelow.
b. Vestibularrehabilitationexercisese.g.CawthorneCookseyexercises5.
i. Theseexercisesaimtohelpthepatientreturntonormalactivitymorequickly.
ii. Movingtheeyesfromsidetosideandupanddownwhileinbedorsittingdownthenmovingthehead,
firstwithyoureyesopenandthenclosed
iii. Otherformsusegazeandgaitstabilisingexercises.Mostexercisesinvolveheadmovement

2. Formostpatientsthemainpriorityiseffectivecontrolofthesymptoms.
a. Foracuteattacks,treatmentsinclude5,8:
i. Betahistinehydrochloride816mguptoTDS
ii. Cinnarizine,1530mgTDSor
iii. Prochlorperazineshouldbereservedforrapidrelieveofacutesymptomsonly8,12tablets510mgor
buccal3mgTDSorinjection12.5mgIMor25mgPRsuppositoryifvomiting
b. Preventivemeasuresforrecurrentattacksinclude:
a. Restrictsaltandfluidintakestopsmokingandrestrictexcesscoffeeoralcohol9,10
b. Betahistinehydrochloride16mgregularlyTDSseemsmosteffectiveinMnire's
c. Cinnarizine1530mgTDS

3. Pointstoconsider
a. Warnpatientswhendrugsmaysedate10.
b. Prochlorperazineislesssedatingthansomeotherrecommendedantihistamines,butmaycausea
dystonicreaction(particularlyinchildrenandyoungwomen)11.
c. Benzodiazepinesarenotrecommended9.
4. Recurrentvertigo
a. Themostimportantfirststepinthemanagementofrecurrentvertigoistodistinguishvertigofrom
'dizziness'.
b. Inattacksofvertigothereisasenseofmobiledisequilibrium("theroomspinning")which,ifsevere,
resultsinuncontrolledstaggeringinonedirectionwhichmaybeonlypreventedbygrabbingasolidobject
10.

5. Epley'smanoeuvre
a.Aimstoremovedebrisfromthesemicircularcanalsanddeposititintheutriclewherehaircellsarenot
stimulated11b.Contraindicationsinclude10:i.Severecarotid
stenosisii.Unstableheartdiseaseiii.Severeneck
disease(cervicalspondylosiswithmyelopathy)iv.Advancedrheumatoid
arthritisConsultationandreferral:
1. Refertosecondarycareif10:

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a. Recurrentseparateepisodes
b. Neurologicalsymptomse.g.dysphasia,paraesthesiaeorweakness
c. Associatedsensorineuraldeafness
d. Ifthereisaninadequatevisualisationoftheentiretympanicmembraneoranabnormality(e.g.
cholesteatoma)
e. Atypicalnystagmuse.g.nonhorizontal,persistingforweeks,changingindirectionordifferingineacheye
f. Positivefistulasign:pressureonthetragusreproducingsymptoms(suggestsendolymphaticfistula
2. IfthepatienthashearingproblemsinadditiontovertigothenreferralshouldbemadetoanENTspecialist.
Othercasesshouldbereferredtoaneurologist10.
3. Whileawaitingreferral:
a. Considersymptomaticdrugtreatmentfornolongerthan1weekbecauseprolongedusemaydelay
vestibularcompensation
b. Itisimportantthatthepersonstopssymptomatictreatment48hoursbeforeseeingaspecialist,asitwill
interferewithdiagnostictestssuchastheDixHallpikemanoeuvre.
c. Iftheperson'ssymptomsdeteriorate,seekspecialistadvice.

Whentoconsiderhospitalization
1. Admitthepatienttohospitaliftheyhaveseverenauseaandvomiting,andareunabletotolerateoralfluids9.
2. Admitorurgentlyreferthepersontoaneurologistiftheyhave:
a. Verysuddenonsetofvertigo(withinseconds)thatpersists.
b. Acutevertigoassociatedwithneurologicalsymptomsorsigns(e.g.newtypeofheadacheespecially
occipital,gaitdisturbance,truncalataxia,numbness,dysarthria,weakness)whichmaysuggestCVA,TIA,
ormultiplesclerosis9.
3. AdmitorreferthepersonasanemergencytoanENTspecialistiftheyhaveacutedeafnesswithoutother
typicalfeaturesofMniresdisease(tinnitusandasensationoffullnessintheear).Suddenonsetunilateral
deafnesswouldsuggestacuteischaemiaofthelabyrinthorbrainstem,butcanalsooccurwithinfectionor
inflammation.
a. Emergencytreatmentmayrestorehearing.Thepersonshouldbeseenwithin12hoursoftheonsetof
symptoms9
4. Theurgencyofreferraldependsontheseverityofsymptoms(e.g.requirementforintravenousfluidsbecause
ofexcessivevomiting)andthesuspecteddiagnosis9.
PatientInformationTheMnire'sSocietywww.menieres.org.ukwww.patient.co.uk/doctor/Vertigo.htm

CompetingInterests
Nonedeclared
AuthorDetails
DaljitSinghSura,GPST3Registrar,NorthStreetMedicalCare,RM14QJ,UKStephenNewell,GeneralPractitioner,
NorthStreetMedicalCare,RM14QJ,UK
CORRESSPONDENCE:DrDaljitSinghSura,GPST3Registrar,NorthStreetMedicalCare,RM14QJ,UK
Email:daljit.singhsura@nhs.net
References
1.RonaldH.Labuguen.InitialEvaluationofVertigo.AmFamPhysician200673:24451,254
2.KuoCH,PangL,ChangR.Vertigopart1assessmentingeneralpractice.AustFamPhysician.
200837(5):34173.BarracloughK,BronsteinA.Vertigo.BMJ.2009339:b34934.HanleyK,O'DowdT,Considine
N.Asystematicreviewofvertigoinprimarycare.BrJGenPract.200151(469):666715.Randy
Swartz.Treatmentofvertigo.AmFamPhysician200571:111522,1129306.Informationfromyourfamilydoctor.
VertigoATypeofDizziness.AmFamPhysician200571:67.Hanley,K.andO'Dowd,T.(2002)Symptomsofvertigo

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ingeneralpractice:aprospectivestudyofdiagnosis.BritishJournalofGeneralPractice52(483),809
812.8.BritishNationalFormulary9.NHSClinicalKnowledgeSummaries10.GPPracticeNotebook11.SwartzR.
Treatmentofvertigo.AmFamPhysician200571:111522,11293012.HamidM.Medicalmanagementofcommon
peripheralvestibulardiseases.CurrOpinOtolaryngolHeadNeckSurg.2010Oct18(5):40712.

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