VERTIGO AYESHA SHAIKH PGY2EMORY FAMILY MEDICINE 09.17.2008
CASE31,female doctor, otherwise healthy, post partum week 5.First episode, sudden feeling of room spinning, while entering patient data in computer, during Family Medicine Clinic… One fine day last year same time!
DIZZINESS• Vertigo• Lightheadedness• Pre syncope• Dys-equilibrium
VERTIGO FALSE SENSE OF MOTION, usually rotational. 2 TYPES1- CENTERAL VESTIBULAR CAUSES(Brain stem or cerebellum)2- PERIPHERAL VESTIBULAR CAUSES( Labyrinth or vestibular nerve)
History Timings Duration Provoking, aggreviating factors Associated symptoms Risk factors for Cardiovascular diseaseQ: When you have dizzy spells , do you feel lightheaded or do you see the world spin around you?Q: Duration of Vertigo and associated symptoms?( differentiate peripheral vs central causes)
Typical Duration of Symptoms for Different Causes of VertigoDuration of episode Suggested diagnosisA few seconds Peripheral cause: unilateral loss of vestibular function; late stages of acute vestibular neuronitis; late stages of Ménières diseaseSeveral secondsto a few minutes Benign paroxysmal positional vertigo; perilymphatic fistulaSeveral minutesto one hour Posterior transient ischemic attack; perilymphatic fistulaHours Ménières disease; perilymphatic fistula from trauma or surgery; migraine; acoustic neuromaDays Early acute vestibular neuronitis*; stroke; migraine; multiple sclerosisWeeks Psychogenic (constant vertigo lasting weeks without improvement)*-Vertigo with early acute vestibular neuritis can last as briefly as two days or as long as one weekor more.Information from references 3, 6, and 12.
Provoking Factors for Different Causes of VertigoProvoking factor Suggested diagnosis•Changes in head position Acute labyrinthitis; benign positional paroxysmal vertigo; cerebellopontine angle tumor; multiple sclerosis; perilymphatic fistula•Spontaneous episodes Acute vestibular neuronitis; cerebrovascular disease (stroke or transient ischemic attack); (i.e., no consistent Ménières disease; migraine; multiple sclerosis•provoking factors)•Recent upper respiratory viral illness Acute vestibular neuronitis•Stress Psychiatric or psychological causes; migraine•Immunosuppression (e.g., immunosuppressive Herpes zoster oticus medications, advanced age, stress)•Changes in ear pressure, Perilymphatic fistula head trauma, excessive straining, loud noises•Information from references 1, 3, 5, 12, and 13.
Associated Symptoms for Different Causes of VertigoSymptom Suggested diagnosisAural fullness Acoustic neuroma; Ménières diseaseEar or mastoid pain Acoustic neuroma; acute middle ear disease (e.g., otitis media, herpes zoster oticus)Facial weakness Acoustic neuroma; herpes zoster oticusFocal neurologic Cerebellopontine angle tumor; cerebrovascular disease;findings) multiple sclerosis (especially findings not explained by single neurologic lesionHeadache Acoustic neuroma; migraineHearing loss Ménières disease; perilymphatic fistula; acoustic neuroma; cholesteatoma; otosclerosis; transient ischemic attack or stroke involving anterior inferior cerebellar artery,herpes zoster oticusImbalance Acute vestibular neuronitis (usually moderate); cerebellopontine angle tumor (usually severe)Nystagmus Peripheral or central vertigoPhonophobia, photophobia MigraineTinnitus Acute labyrinthitis; acoustic neuroma; Ménières diseaseInformation from references 1, 6, and 12 through 14.
Table 5Causes of Vertigo Associated with Hearing LossDiagnosis Characteristics of hearing lossAcoustic neuroma Progressive, unilateral, sensorineuralCholesteatoma Progressive, unilateral, conductiveHerpes zoster oticus(i.e., Ramsay Hun syndrome) Subacute to acute onset, unilateralMénières diseases Sensorineural, initially fluctuating, initially affecting lowerfrequencies; later in course: progressive, affecting higher frequenciesOtosclerosis Progressive, conductivePerilymphatic fistula Progressive, unilateralTransient ischemic attack orstroke involving anterior inferior cerebellarartery or internal auditory artery Sudden onset, unilateralInformation from references 9, 12, and 13.
Distinguishing Characteristics of Peripheral vs. Central Causes of VertigoFeature Peripheral vertigo Central vertigoNystagmus Combined horizontal and torsional; Purely vertical, horizontal, or torsional inhibited by fixation of eyes onto object; ; not inhibited by fixation of eyes onto object; fades after a few days; does not change may last weeks to months direction with gaze to either side ; may change direction with gazeImbalance Mild to moderate; able to walk Severe; unable to stand still or walkNausea May be severe Varies, vomitingHearing loss,tinnitus Common RareNonauditory Rare CommonneurologicsymptomsLatency followingprovocativediagnostic Longer (up to 20 seconds) Shorter (up to 5 seconds)maneuver)Information from references 14 and 15.
Physical ExamSpecial attention to head and neckCardiovascular and neurologic symptomsProvocative diagnostic tests
Physical ExamVertical nystagmus is 80% sensitive for central lesions.Horizontal nystagmus for peripheral lesions.Rhomberg sign : sensitivity 19 % only for peripheral causes.Dix-Hallpike maneuver PPV 83%, NPV 52 %.
Clues to Distinguish Between Peripheral and Central VertigoClues Peripheral vertigo Central vertigoFindings on Latency of symptoms NoneDix-Hallpike and nystagmus 2 to 40 secondsmaneuverSeverity of vertigo Severe MildDuration of nystagmus Usually< 1 minute Usually>1 minuteFatigability* Yes NoHabituation† Yes NoOther findingsPostural instability Able to walk; Falls while walking; unidirectional instability severe instabilityHearing lossor tinnitus Can be present Usually absentOther neurologicSymptoms Absent Usually present*-Response remits spontaneously as position is maintained.†-Attenuation of response as position repeatedly is assumed.Information from references 3 and 4.
Diagnosis History Physical Exam: Orthostatic vital signs, and Otoscopic examination, Neurologic Exam: Dix-Hallpike Maneuver ( central vs Peripheral) Complete Audiometric Testing for suspected Menier’s disease No LAB testing! Brain imaging : MRI with contrast for acute vertigo and Sensorineural hearing loss, MRA for vertebrobasilar circulation
Disorder Duration Auditory Prevalence Peripheral or symptoms central vertigoBenign paroxysmal Seconds No Common Peripheralpositional vertigoPerilymphatic fistula (head Seconds Yes Uncommon Peripheraltrauma, barotrauma)Vascular Ischemia,TIA Seconds to hours Usualy not Uncommon Central or peripheralMeniere’s disease Hours yes common peripheralSyphillis Hours yes Uncommon centralVertiginous migraine Hours No Common CentralLabyrinthitis Days Yes common peripheralVascular Ischemia: Stroke Days Usually not Uncommon Central or peripheralVestibular neuronitis Days No Common PeripheralAnxiety disorder Variable Usually not Common UnspecifiedAcoustic neuroma months yes Uncommon PeripheralMultiple sclerosis Months no uncommon centralVestibular ototoxicity months yes uncommon peripheral
General Treatment Principles Medication for Acute Vertigo that lasts for few hours to several days Medications have various combinations of acetylecholine, dopamineand histamine receptor antagonism. Benzodiazepines enhance GABA action ( GABA is inhibitory neurotransmitter in vestibular system)
Strength of RecommendationKey clinical recommendation•The canalith repositioning procedure (Epley maneuver) is recommended in patients with benign paroxysmalpositional vertigo. A•The modified Epley maneuver also is effective in patients with benign paroxysmal positional vertigo.B•Vestibular suppressant medication is recommended for symptom relief in patients with acute vestibularneuronitis. C•Vestibular exercises are recommended for more rapid and complete vestibular compensation in patients withacute vestibular neuronitis. B•Treatment with a low-salt diet and diuretics is recommended for patients with Ménières disease and vertigo.B•Effective treatments for vertiginous migraine include migraine prophylaxis (e.g., tricyclic antidepressants, betablockers, calcium channel blockers), migraine-abortive medications (e.g., sumatriptan [Imitrex]), and vestibularrehabilitation exercises B•Selective serotonin reuptake inhibitors can relieve vertigo in patients with anxiety disorders. Because of sideeffects, slow titration is recommended.BA = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-orientedevidence; C = consensus, disease-oriented evidence, usual practice, opinion, or case series. See page 1046 formore information.
Medications Meclizine* (Antivert) 12.5 to 50 mg orally every 4 to 8 hour Dimenhydrinate* (Dramamine) 25 to 100 mg orally, IM, or IV every 4 to 8 hours Diazepam (Valium) 2 to 10 mg orally or IV every 4 to 8 hours Lorazepam (Ativan) 0.5 to 2 mg orally, IM, or IV every 4 to 8 hours Metoclopramide (Reglan) 5 to 10 mg orally every 6 hours 5 to 10 mg by slow IV every 6 hours Prochlorperazine (Compazine) 5 to 10 mg orally or IM every 6 to 8 hours 25 mg rectally every 12 hours 5 to 10 mg by slow IV over 2 minutes Promethazine (Phenergan) 12.5 to 25 mg orally, IM, or rectally every 4 to 12 hours
Vestibular Rehabilitation Exercises These exercises train the brain to use alternative visual and proprioceptive clues to maintain balance and gait. Improve postural control during the first month after acute unilateral vestibular lesions resulting from vestibular neuronitis.
Treatment of Specific Disorders 1- BPPV (Usually posterior canal Calcium Debris) MEDS..? Head Rotation Maneuvers Eply ManeuverContraindication: Severe carotid stenosis, unstable heart disease, severe neck diseaseSuccess rate: 80 % after one treatment, 100% with repeated treatments.Recurrence rates: 15% /year, 20% @ 20 months, and 37% @ 60 months.
Treatment of specific Disorders 2- Vestibular Neuronitis ( Acute Prolonged Vertigo) Symptom relief using vestibular suppressant medications, followed by vestibular exercises. Vestibular compensations occurs more rapidly and more completely if the patient begins twice-daily vestibular rehabilitation exercises soon after symptom control with medications.
Treatment of specific disorders 3-Menier’s Disease (Distension of Endolymphatic compartment due to impaired endolymphatic filtration and excretion) Low salt diet ( < 1-2 gm/day) Diuretics ( combo HCTZ and Triamterene) Surgery in rare cases - ablation of vestibular hair cells)
4- Vascular Ischemia (Sudden onset of vertigo with additional symptoms eg diplopia, ataxia, dysphagia, dysarthria) TIA /Stroke: BP control, Cholesterol Lowering , smoking cessation, inhibition of platelet function, anticoagulation Vestibualr suppressant medications plus minimal head maneuver on first day, then initiate rehabilitation Vestibular stents for symptomatic critical vertebral artery stenosis.
7- Psychiatric Disorders( Anxiety , Panic disorders more common than depression; Hyperventilation is the cause.) Vesibular supressants and Benzodiazepines- transient to inadequate relief. SSRI show better relief. Cognitive behaviour therapy may be helpful.
Physiologic Vertigo Motion sickness: incongruence in the sensory input from the vestibular, visual, and somatosensory systems.Visual system does not sense the movement. Bring systems back in congruence! Eg watch horizon when on a boat.also scopolamine patch behind ear 4 hours before boating.
Disorder Duration Auditory Prevalence Peripheral or symptoms central vertigoBenign paroxysmal Seconds No Common Peripheralpositional vertigoPerilymphatic fistula (head Seconds Yes Uncommon Peripheraltrauma, barotrauma)Vascular Ischemia,TIA Seconds to hours Usualy not Uncommon Central or peripheralMeniere’s disease Hours yes Common PeripheralSyphillis Hours yes Uncommon centralVertiginous migraine Hours No Common CentralLabyrinthitis Days Yes Common PeripheralVascular Ischemia: Stroke Days Usually not Uncommon Central or peripheralVestibular neuronitis Days No Common PeripheralAnxiety disorder Variable Usually not Common UnspecifiedAcoustic neuroma months yes Uncommon PeripheralMultiple sclerosis Months no uncommon centralVestibular ototoxicity months yes uncommon peripheral
Internet resources for patient educationhttp://www.youtube.com/watch?v=hhinu_ohttp://www.youtube.com/watch?v=NQr7MKhttp://www.youtube.com/watch?v=eOuzUi5
References Labuguen R. Initial Evaluation of Vertigo. American Family Physician. January 15, 2006. Swartz R, Longwell P. Treatment of Vertigo. American Family Physician. March 15, 2005.