Vertigo resident survival guide

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Moises Romo M.D.

Synonyms and Keywords: vertigo, dizziness, approach to vertigo, vertigo workup, vertigo management, vertigo workup, approach to dizziness

Overview

Vertigo is a specific type of dizziness, and a major symptom of a balance disorder. Vertigo is characterized by a sudden spinning sensation that occurs internally or externally, and usually occurs when you move your head quickly. This sensation occurs while the body is actually stationary with respect to the surroundings. The effects of vertigo may be slight; it can cause nausea and vomiting and, in severe cases, it may give rise to difficulties with standing and walking.

Causes

Life Threatening Causes

Life-threatening causes include conditions that may result in death or permanent disability within 24 hours if left untreated.

• Brainstem stroke
• Cyanide poisoning
• Drug overdose
• Malignant hypertension

Common Causes

• Benign paroxysmal positional vertigo
• Cerebellar stroke
• Meniere's disease
• Vertebrobasilar transient ischemic attack
• Vestibular migraine
• Vestibular neuritis

Diagnosis

• Shown below is an algorithm summarizing the diagnosis of vertigo according to the American Academy of Neurology guidelines:

Subjective sensation of movement of objects around us or of our own body, usually a spinning sensation.

Vertigo

Symptoms of nausea, vomiting, hearing loss, tinnitus, ear fullness, and otalgia + History of upper respiratory infection and/or drug ingestion

Symptoms of polyuria, polydipsia, weight gain, and hair loss + History of chronic disorders

Symptoms of neurologic deficit (slurred speech and diplopia) + History of head trauma and/or demyelinating disease

Peripheral vertigo

Systemic vertigo

Central vertigo

Common •BPPV •Vestibular neuronitis •Meniere syndrome •Acute otitis media Uncommon •Ototoxic drugs •Perilymphatic fistula •Acoustic neuroma

•Diabetes •Hypothyroidism

Common •Cerebellar stroke •Vertebrobasilar insufficiency •Brainstem stroke •Migraine Uncommon •CNS infection •Multiple sclerosis

• The clinical diagnosis of benign paroxysmal positional vertigo according to The American Academy of Otolaryngology is as follows:

Diagnosis of benign paroxysmal positional vertigo (BPPV)

Presence of all the following criteria	Continuous periods of vertigo triggered by changes in head position.
	Vertigo related with twisting, positive nystagmus is triggered by the Dix-Hallpike maneuver.
	Presence of a quiescence period between the execution of the Dix-Hallpike maneuver and the beginning of vertigo and nystagmus.
	The triggered vertigo and nystagmus rises and then solves within 60 seconds from the onset.

Adapted from The American Academy of Otolaryngology guidelines for benign paroxysmal positional vertigo (DO NOT EDIT).

Treatment

Treatment of vertigo will vary depending on the underlying cause:

• To view the treatment of benign paroxysmal positional vertigo click here.
• To view the treatment of Meniere disease click here.
• To view the treatment of orthostatic hypotension click here.
• To view the treatment of panic attack click here.
• To view the treatment of transient ischemic attack click here.
• To view the treatment of stroke click here.
• To view the treatment of vestibular migraine click here.

Do's

• Always ask the patient what do they mean by vertigo. Vertigo may have a different meaning among patients; while vertigo may represent a vestibular condition, presyncope directs to a cardiovascular problem, or disequilibrium a neurological or psychiatric one.
• Intentionally ask for any history of possible intoxication, medications used, and exposures. A full history review may disclose vertigo due to trauma or an intoxication.
• Ask for any eliciting or exacerbating features of vertigo. Dix-Hallpike maneuver may easily detect a benign paroxysmal positional vertigo (BPPV) and differentiate it from an orthostatic hypotension.
• Perform a full neurological examination. A head-impulse, nystagmus, test of skew (HINTS) can differentiate between a central from a peripheral cause.
• When taking vital signs, remember to measure blood pressure in standing and supine position.
• Perform a Romberg test. A positive Romberg test may disclose a peripheral etiology.

Don'ts

• Do not perform imaging laboratory tests as routine.
• Do not forget about psychiatric causes. Many times psychiatric conditions, such as panic attacks, may mimic vertigo.
• Do not forget abut orthostatic hypotension. Orthostatic hypotension is a very common cause of dizziness, especially in elderly people due to blood vessels rigidity (arteriosclerosis).
• Do not miss transient ischemic attack (TIA). TIA is one of the most missed diagnosis when a patient presents with vertigo.
• When looking after benign paroxysmal vertigo (BPV), do not perform Dix-Hallpike only once. BPPV only comes positive in around 70% of the times with first attempt, several attempts may be necessary.
• Do not give any kind of pharmacologic treatment for BPPV.

References

Vertigo Resident Survival Guide
Overview
Causes
Diagnosis
Treatment
Do's
Don'ts