Vertigo

Definition
A symptom of illusion of movement.

Synonyms
Dizziness

Classification
Peripheral or central

Etiology
“Dizziness”:
40% – peripheral vestibular dysfunction
10% – central brainstem vestibular lesion
15% – psychiatric disorder
25% – other, such as presyncope or disequilibrium

DDx
Peripheral: Benign paroxysmal positional vertigo, Vestibular neuritis, Herpes zoster oticus (Ramsay Hunt syndrome), Meniere’s disease, Labyrinthine concussion, Perilymphatic fistula, Semicircular canal dehiscence syndrome, Cogan’s syndrome, Recurrent vestibulopathy, Acoustic neuroma, Aminoglycoside toxicity, Otitis media

Central: Migrainous vertigo, Brainstem ischemia, Cerebellar infarction and hemorrhage, Chiari malformation, Multiple sclerosis, Episodic ataxia type 2

Red Flag
FND, Focal Neck Pain, Hx Head Trauma, Change in LOC, Acute onset

Hx
HPI, Medications, PMHx, Social Hx, GI Hx, Neuro Hx, Headache Hx, Cardinal 7 Hx

Elements of Hx that can differentiate causes:

  • Past Hx of stroke, migraines, or head trauma
  • Increased Sx with cough, sneeze, exertion, or loud noises (Tullio phenomenon) – perilymphatic fistula
  • Cisplatin and aminoglycosides can have vestibular toxicity and dilantin can have cerebellar toxicity
  • All vertigo should be aggravated by motion of the head
  • Time course:
    • Minutes: BPV
    • Hours, not recurrent: transient brainstem or labrynth ischemia, migraine
    • Hours, recurrent: Meniere’s Disease or recurrent vestibulopathy
    • Days: MS, Vestibular Neuritis, infarction of the brainstem or labrynth
  • Head trauma – perilymphatic fistula, labrynthine concussion, ischemia, BPV
  • Recent viral illness – vestibular neuritis, BPV
  • Deafness and tinnitus – Meniere’s Disease
  • Focal neck pain – vertebral artery dissection
  • Headache, phonophobia, photophobia – Migranous vertigo
  • Hx of MS

PEx
Neurologic Exam, Gait, CN Exam, Postural Vitals, Hearing Assessment, Otoscopy, Weber and Rinne Tests, Dix-Hallpike Maneuver

Elements of the PEx that can help differentiate causes:

  • Motion of the head
  • Specific postures or movements trigger episodes – BPV
  • Nystagmus
    • Unilateral direction to fast-beat – peripheral, fast-beat to the unaffected ear
    • Bilateral direction to fast-beat – central
  • Diplopia, dysarthria, dysphagia, weakness, or numbness – Vertebrobasilar stroke
  • Gait instability
    • Peripheral – able to walk, but will fall to the side of the lesion
    • Central – Unable to walk, will fall in either direction
  • Dix-Hallpike – Latency, transience, fatigability, and combined horizontal/torsional nystagmus are consistent with BPV
  • Caloric ear testing
  • Infuse cold and warm water into the ear, ensuring contact with the tympanum
  • Normally: fast-beat nystagmus to the infused ear with warm water, and away with cold
  • No response: lesion of the vestibular system of that ear

    Investigations
    EKG, Head CT, Head MRI, Audiometry, Electronystagmography, Vestibular Evoked Myogenic Potentials, Brainstem Auditory Evoked Potentials

    Management
    Medications: Antihistamines, Phenothiazine antiemetics, Benzodiazepines, betahistine (Serc, H3 Antagonist)
    Physiotherapy: vestibular retraining exercises Generally: Laying around is worse, activity promotes retraining of the vestibular mechanism

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