23 Nov Vertigo
You’ve seen a 45yo patient with a sudden onset of vomiting, dizziness, ‘off balance’ and bumping into things. Most of you will have encountered this presentation many times before and attributed the symptoms to a minor illness. However. A small (albeit important) proportion of these will have a serious cause.
This week we look at vertigo. No, it’s not a condition, rather a symptom in its own right. Vertigo is a very specific type of dizziness where the patient perceives movement and spacial disorientation (described as perceived movement, spinning, floor moving etc) so clarify what they mean when a patient describes ‘dizziness’. Other vague unhelpful descriptions that need exploring are giddiness, fuzziness, fuzzy headed etc. Im sure you’ve come across this kind of history before! Keep digging until you have a clear understanding of the symptoms.
If you’ve never experienced vertigo before, it’s the sensation that arises from the playground game of ‘dizzy dinosaurs’. If you’ve never played dizzy dinosaurs, quite frankly you haven’t lived! Vertigo is also felt if you’ve been ‘well oiled’ after a night out. You know, that feeling that the bed is trying its best to spill you onto the floor, which of course none of you have experienced. Ahem!!
The cerebellum is responsible for processing information pertaining to balance and proprioception. Therefore the sensation of vertigo originates from the cerebellum. So all of a sudden vertigo becomes a potentially sinister sign, does it not?
We need to be able to differentiate between a peripheral cause (i.e benign. An ear or peripheral nerve problem) and a central cause (i.e serious. A brain problem). It comes down to careful history and examination.
Peripheral causes of vertigo are- Benign paroxysmal positional vertigo (BPPV), vestibular neuritis, labrynthitis or menières disease (we will explore these in further detail shortly).
Central causes include posterior brain ischaemia (i.e stroke), multiple sclerosis (MS), alcohol intoxication, migraine, brain tumour, acoustic neuroma.
Careful history and examination should enable you to reliably exclude central neurological pathology. Sudden onset, continuous vertigo, cardiovascular risk factors, associated headache or head injury all increase the suspicion of a central cause, whilst hearing loss, severe nausea and vomiting, ear pain and absent neurological signs would more likely indicate a benign peripheral aetiology.
Cranial nerve and cerebellar function testing (proprioception, gait, coordination) in addition to the HINTS exam will all help determine the likely cause of a patients vertigo. This HINTS exam video is great, because it shows you what a reassuring and a worrying examination looks like without getting lost and confused in a written explanation by me!
The table below summarises how the HINTS exam reflects the probable aetiology.
Central vertigo will usually be referred and managed acutely, especially if it is thought to be due to stroke which would be referred same day (check local stroke centre admission criteria whether they offer hyper acute stroke services to posterior stroke). Whilst a patient with more gradual onset symptoms (weeks- months) would likely be referred urgently (<2wks) +/- MRI whilst awaiting referral. Ultimately, the urgency of referral will be influenced by the suspected cause. E.g. a patient with central vertigo after drinking 8 pints of beer over 2 hrs (but they can usually manage at least 12-15 pints, or so they say!) is unlikely to be admitted unless coincidental stroke is suspected or other concerns exist.
Vestibular migraine is probably the most commonly seen cause of central vertigo, presents with occipital pressure headache, nausea vomiting and visual disturbance but can be difficult to distinguish from Menières or stroke.
Where the vertigo is thought likely to be of a peripheral origin, most of these patients will be managed in the community unless other concerns for their safety and welfare exist. You’d want to consider admitting those with intractable vomiting who are, or are at risk of dehydration. Social circumstances and comorbid status will also influence your decision making. For e.g. you’d probably think differently about managing an older adult with mobility impairment who lives alone with the toilet upstairs, compared with a normally fit active, independent adult living with a partner for instance.
Vestibular neuronitis/ labrynthitis – Usually presents with sudden or rapid onset of continuous vertigo, nausea +/- vomiting, (hearing loss +/- tinnitus suggests labrynthitis), and there may be current or recent upper respiratory tract infection. Rest and immobility typically reduce the severity of symptoms significantly but will usually benefit from antiemetic treatment depending on severity of symptoms.
A short course (3days) of oral prochlorperazine, cinnarazine, cyclizine or promethazine for milder symptoms usually helps but more severe symptoms will require prochlorperazine buccal tablets (available over the counter) or IM injection (clearly not available over the counter. Well, not a legitimate counter anyway!) to rapidly reduce symptoms.
Symptoms can last days – weeks followed by spontaneous resolution. Refer if no improvement <1wk and if persistent vertigo >6wks.
Benign paroxysmal positional vertigo (BPPV) presents with abrupt onset of vertigo brought on by specific head movements. Turning over in bed is a common presentation. Vertigo in BPPV will be episodic rather than continual, and symptoms will be elicited through head movement. Most commonly presents among 50-70yr but all ages are affected.
The Dix- Hallpike test is diagnostic for BPPV and sure fire way to get you taken off the patients Christmas card list.
Symptomatic treatments usually are ineffective but vestibular wizardry can help (i.e. canalith repositioning procedures). The Epley manoeuvre can be helpful and should ideally be performed at first presentation if expertise and time (that scuppers primary care then) allows. Brandt-Daroff exercises can be done by the patient at home to manage their symptoms, essentially a modified Epley manoeuvre.
Refer to vestibular rehabilitation, usually with ENT or physiotherapy depending on local arrangements (Jupiters solar orbit phase probably plays a part too im sure), if canalith repositioning manoeuvres aren’t available or concerns about their safety exist (e.g. patients with severe neck or back problems, unstable cardiac disease, suspected vertebrobasilar disease, carotid stenosis, or morbid obesity), symptoms haven’t resolved after repeated canalith manoeuvres, signs are atypical or the diagnosis is called into question.
Menières disease episodes of spontaneous vertigo are not provoked by position change, and last far longer than in BPPV (30 minutes- hours). Tinnitus, fluctuating hearing loss, and fullness in the ear are often described in menières but not in BPPV or vestibular neuronitis. History provides the diagnosis of Menières and no specific test is diagnostic. Diagnosis is usually formally made only after ENT review and audiometric testing.
Management is as for vestibular neuronitis but trial of Betahistine can be considered to reduce severity and frequency of vertigo episodes followed by referral to ENT if it proves ineffective.
Sources (just to prove that this isn’t all made up)
NICE CKS vertigo- https://cks.nice.org.uk/topics/vertigo/
HINTS exam video – youtube.com/watch