Vertigo resident survival guide
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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.
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:[1]
| 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).[1]
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.[2]
- 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.[3]
- Perform a Romberg test. A positive Romberg test may disclose a peripheral etiology.[4]
Don'ts
- Do not perform imaging laboratory tests as routine.[5]
- Do not forget about psychiatric causes. Many times psychiatric conditions, such as panic attacks, may mimic vertigo.[6]
- 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).[7]
- 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.[8]
- Do not give any kind of pharmacologic treatment for BPPV.[9]
References
- ↑ 1.0 1.1 Bhattacharyya, Neil; Gubbels, Samuel P.; Schwartz, Seth R.; Edlow, Jonathan A.; El-Kashlan, Hussam; Fife, Terry; Holmberg, Janene M.; Mahoney, Kathryn; Hollingsworth, Deena B.; Roberts, Richard; Seidman, Michael D.; Steiner, Robert W. Prasaad; Do, Betty Tsai; Voelker, Courtney C. J.; Waguespack, Richard W.; Corrigan, Maureen D. (2017). "Clinical Practice Guideline: Benign Paroxysmal Positional Vertigo (Update)". Otolaryngology–Head and Neck Surgery. 156 (3_suppl): S1–S47. doi:10.1177/0194599816689667. ISSN 0194-5998.
- ↑ Edlow JA, Gurley KL, Newman-Toker DE (April 2018). "A New Diagnostic Approach to the Adult Patient with Acute Dizziness". J Emerg Med. 54 (4): 469–483. doi:10.1016/j.jemermed.2017.12.024. PMC 6049818. PMID 29395695.
- ↑ Kattah JC, Talkad AV, Wang DZ, Hsieh YH, Newman-Toker DE (November 2009). "HINTS to diagnose stroke in the acute vestibular syndrome: three-step bedside oculomotor examination more sensitive than early MRI diffusion-weighted imaging". Stroke. 40 (11): 3504–10. doi:10.1161/STROKEAHA.109.551234. PMC 4593511. PMID 19762709.
- ↑ Kroenke K, Lucas CA, Rosenberg ML, Scherokman B, Herbers JE, Wehrle PA, Boggi JO (December 1992). "Causes of persistent dizziness. A prospective study of 100 patients in ambulatory care". Ann. Intern. Med. 117 (11): 898–904. doi:10.7326/0003-4819-117-11-898. PMID 1443950.
- ↑ Kroenke K, Lucas CA, Rosenberg ML, Scherokman B, Herbers JE, Wehrle PA, Boggi JO (December 1992). "Causes of persistent dizziness. A prospective study of 100 patients in ambulatory care". Ann. Intern. Med. 117 (11): 898–904. doi:10.7326/0003-4819-117-11-898. PMID 1443950.
- ↑ Muncie HL, Sirmans SM, James E (February 2017). "Dizziness: Approach to Evaluation and Management". Am Fam Physician. 95 (3): 154–162. PMID 28145669.
- ↑ Savitz SI, Caplan LR (June 2005). "Vertebrobasilar disease". N. Engl. J. Med. 352 (25): 2618–26. doi:10.1056/NEJMra041544. PMID 15972868.
- ↑ Hilton M, Pinder D (2004). "The Epley (canalith repositioning) manoeuvre for benign paroxysmal positional vertigo". Cochrane Database Syst Rev (2): CD003162. doi:10.1002/14651858.CD003162.pub2. PMID 15106194.
- ↑ Edlow JA, Gurley KL, Newman-Toker DE (April 2018). "A New Diagnostic Approach to the Adult Patient with Acute Dizziness". J Emerg Med. 54 (4): 469–483. doi:10.1016/j.jemermed.2017.12.024. PMC 6049818. PMID 29395695.