The document discusses the definition, epidemiology, diagnosis, and management of vertigo, characterized by the sensation of motion without actual movement. It highlights a significant lifetime prevalence of vertigo, particularly among females and the elderly, and outlines diagnostic approaches and treatment options, including vestibular rehabilitation and pharmacotherapy. Effective management requires accurate diagnosis, with a focus on alleviating anxiety and addressing underlying conditions while utilizing specialized exercises and medications like betahistine.

1. Diagnosis and
Management
of Vertigo

2. Vertigo- Definition
‘The sensation of motion when no motion is occurring relative to
earth’s gravity’1
A feeling of movement, a sensation as if the external world were
revolving around the patient (objective vertigo) or as if he himself
were revolving in space (subjective vertigo)2
Sense of rotation
Symptom expression of disorder of vestibular system
1. Committee on Hearing and Equilibrium , Otolaryngol Head Neck Surg 1995;113:181–5. 2. International Classification of Disease [Online] Access at
http://www.icd9data.com/2012/Volume1/780- 799/780-789/780/780.4.htm

3. Vertigo- Epidemiology
The lifetime prevalence of vertigo in adults (18–79 years) is 7.4%
The one-year prevalence is 4.9%, & the one year incidence is 1.4%.
Female preponderance is observed among individuals with vertigo
(one-year prevalence ratio for male to female 1:2.7)
In patients >65 years prevalence rate is 8-9%
3 times more frequent in the elderly compared to the young
Neuhauser HK, von Brevern M, Radtke A, et al. Neurology 2005;65:898–904.

4. Vertigo Impact
Recurrent in 88%
of affected
patients
Affects daily lives
in 80% of
persons
Reduced quality
of life
Psychiatric
problems
Sick leaves and
frequent medical
consultations
Falls in Elderly
Neuhauser HK, von Brevern M, Radtke A, et al. Neurology 2005;65:898–904.

5. Diagnosis
Dizziness is a common presenting complaint
Determination of accurate cause remains challenging
Accurate diagnosis helps in appropriate intervention and resolution of
symptoms
In a study of 3400 patients over 70 years of age an accurate diagnosis
was possible in more than 75%
1. Katsarkas A. Geriatrics 2008;63:18–20. 2. Moeller JJ, Kurniawan J, Gubitz GJ, et al. Can J Neurol Sci 2008;35:335–41.

6. Diagnosis
◦ Proper history and a good clinical examination can provide a
diagnosis in the majority of the patients.(75% cases accurate
diagnosis possible)
Systematic approach to patients with vertigo
1)Presence of vertigo is established
2)Duration of vertiginous event and recurrence is determined
3)Type of nystagmus is observed
4)Additional co occuring symptoms
Garg RK, Kothari S. Guidelines on Vertigo, Indian Academy of Neurology

7. Duration of vertiginous event and recurrence
1) BPPV: few seconds to <1 min [recurrent]
2)Menieres disease:20 min to 20 hr/few hr[recurrent]
3)Migraine associated vertigo: >few min to 60min [recurrent]
4)Acute long duration:vestibular neuritis,labyrinthitis,labyrinthine
concussion/ischemia
cerebellar infarct/ischemia,brain stem infarct/ischemia

8. Nystagmus characteristics
Peripheral:
Horizontal/tortional, fixed direction, suppressed by optical fixation,
follows Alexanders and Ewalds law
Central:
Vertical horizontal tortional, not suppressed by optical fixation,
direction changing,

9. Additional symptoms that aid in making diagnosis
A) Auditory symptoms:hearing loss,tinnitus,aural fullness
B) Nausea: Seen in both peripheral > central
C) Focal neurological signs: dysarthria, inco-ordinationo
D) Imbalance
Patients with central cause have prolonged time for symptoms to
subside compared to
relatively faster central compensation that is possible and typical of
peripheral causes

10. Test during examination
1. Spontaneous nystagmus
2. Gaze nystagmus
3. Smooth pursuit
4. Saccades
5. Fixation suppression
6. Head thrust
7. Headshake
8. Dynamic visual acuity
9. Hallpike positioning
10. Static positional
11. Limb co-ordination
12. Romberg stance
13. Gait observation
14. Specialized tests
Garg RK, Kothari S. Guidelines on Vertigo, Indian Academy of Neurology

11. The Head Thrust Test
Edlow JA, Newman-Toker DE, Savitz SI. Diagnosis and initial management of cerebellar infarction. Lancet Neurol 2008;7:951–964.

12. Dix-Hallpike Positioning Test
Parnes LS, Agrawal SK, Atlas J. Diagnosis and management of benign paroxysmal positional vertigo (BPPV). CMAJ. 2003:169:681-693

13. Supine Lateral head Turns
Lee S-H, Kim JS. Benign Paroxysmal Positional Vertigo. Journal of Clinical Neurology (Seoul, Korea). 2010;6(2):51-63. doi:10.3988/jcn.2010.6.2.51.

14. Test of Skew
Skew deviation is vertical ocular misalignment that results from a
right-left imbalance of vestibular neural firing.
Skew deviation is generally detected by alternate cover testing
Skew deviation in acute vestibular syndrome was strongly linked to
the presence of brainstem lesions.
Garg RK, Kothari S. Guidelines on Vertigo, Indian Academy of Neurology

15. 3 dangerous, subtle occulomotor signs
“INFARCT”
IN - impulse normal
FA - fast phase alternating
RCT – re-fixation on cover test
Garg RK, Kothari S. Guidelines on Vertigo, Indian Academy of Neurology

16. Horizontal Head-Impulse Test,
Nystagmus and Test of Skew
(HINTS)
HINTS has recently been shown to detect
brainstem and cerebellar stroke with greater
sensitivity than neuro-imaging
Garg RK, Kothari S. Guidelines on Vertigo, Indian Academy of Neurology

17. Vertigo
Acute
(Head Impulse
test)
Positive
Peripheral
lesion
(vestibulopathy)
Negative
Central lesion
Recurrent
(Dix Hallpike
test)
Positive
Posterior canal
involvement
Negative
(supine roll test)
Positive
Horizontal canal
involvement
Negative
Other causes
Algorithm
For various tests
Garg RK, Kothari S. Guidelines on Vertigo, Indian Academy of Neurology

18. Menière’s disease
BPPV
Vestibular
paroxysmia
Bilateral
vestibulopathy Acute
unilateral
vestibulopathy
The five most frequent peripheral vestibular disorders:
acute unilateral and bilateral vestibulopathy,
vestibular paroxysmia, BPPV, Menière’s disease

19. Vertigo Triggers
Thomas S, Cherian A. Guidelines on Vertigo, Indian Academy of Neurology
Triggers Suspected Diagnosis
Change of head posture BPPV, vestibular migraine,
central positional vertigo
Menstruation, sleep
deprivation
Vestibular migraine
Elevators, closed spaces Panic attacks
Loud noise, Valsalva Fistula syndromes

20. Duration of events
*Vertigo with early acute vestibular neuritis can last as briefly as 2 days or as long as 1 week or more.
Duration Suspected Diagnosis
A few seconds Peripheral cause: unilateral loss of vestibular function; late stages of
acute vestibular neuronitis; late stages of Ménière’s disease
Several seconds to a
few minutes
Benign paroxysmal positional vertigo; perilymphatic fistula
Several minutes to 1
hour
Posterior transient ischemic attack; perilymphatic fistula
Hours Ménière’s disease; perilymphatic fistula from trauma or surgery;
migraine;
acoustic neuroma
Days Early acute vestibular Neuronitis*; stroke; migraine; multiple
sclerosis
Weeks Psychogenic (constant vertigo lasting weeks without improvement)
Garg RK, Kothari S. Guidelines on Vertigo, Indian Academy of Neurology

21. Approach to a vertigo patient
Cont… on next
slide
Patient presents with dizziness
History of medication, caffeine, nicotine, and alcohol intake;
history of head trauma or whiplash injury
False sense of motion of
spinning sensation
Vertigo
Headache and other
symptoms s/o migraine
Hearing loss
Migraine
Neurological deficit
CNS causes Other causes:
traumatic, cervicogenic
Neuro-imaging
Kanikanna MA, Kandadai RM, Jabeen SA, Guidelines on Vertigo, Indian Academy of Neurology

22. Approach to a vertigo patient (cont)
Hearing loss
Yes No
No fever:
Ménière’s Disease
Fever:
labyrinthitis
Vestibular neuritis:
viral infection
BPPV
Perform Dix-Hallpike
Kanikanna MA, Kandadai RM, Jabeen SA, Guidelines on Vertigo, Indian Academy of Neurology

23. Investigations
Test Evaluates
Electronystagmography VOR + LSCC
Videonystagmography VOR + LSCC + oculomotor system
Craniocorpography VSR
Video head impulse test VOR of 6 SCCs
Subjective visual vertical Otolithic system
Stabilometry VSR + stability
Vestibular evoked myogenic potential Saccule + inferior vestibular nerve
Pure tone audiometry Middle ear/cochlear/retrocochlear
function
Brainstem evoked response audiometry Retrocochlear
electrocochleography Cochlear function
nerve conduction velocity; and
somatosensory evoked potential
Neural conduction in the peripheral
nerves and in the ascending
and descending columns
Biswas A, Guidelines on Vertigo, Indian Academy of Neurology
VOR: vestibulo-ocular reflex; LSCC: lateral semicircular canal;
VSR: vestibulospinal reflex; SCCs: semicircular canals.

24. Distinguishing Features (1)
Test Peripheral (labyrinth) Central (brainstem
or cerebellum)
Direction of associated nystagmus Unidirectional; fast phase
opposite lesion
Bidirectional or
unidirectional
Purely horizontal nystagmus without
torsional component
Uncommon Common
Vertical or purely torsional nystagmus Never present May be present
Visual fixation Inhibits nystagmus and
vertigo
No inhibition
Severity of vertigo Marked Often mild
Direction of spin Toward fast phase Variable
Direction of fall Toward slow phase Variable
Kothari S, Guidelines on Vertigo, Indian Academy of Neurology

25. Imaging studies in vertigo
1)Acute vertigo with neurological signs, central
nystagmus,profound imbalance
2)Older patients with vascular risk factors even if
other characters support a peripheral cause
3)Patients with auditory symptoms ,supporting
peripheral cause imaging is less necessary.

26. Distinguishing Features (2)
Test Peripheral (labyrinth) Central (brainstem or
cerebellum)
Duration of symptoms Finite (minutes, days,
weeks) but
recurrent
May be chronic
Tinnitus and/or deafness Often present Usually absent
Associated CNS abnormalities None Extremely common (e.g.,
diplopia,
hiccups, cranial
neuropathies,
dysarthria)
Common causes BPPV, infection
(labyrinthitis),
Ménière’s, neuronitis,
ischemia,
trauma, toxin
Vascular, demyelinating,
neoplasm
Kothari S, Guidelines on Vertigo, Indian Academy of Neurology

27. Vertigo
management

28. Empathy and Reassurance
Most patients with acute vertigo are very anxious
Alleviate their anxiety by explaining cause of
vertigo and nature of the disorder
Positive counseling
Kirtane MV, Biswas A, Guidelines on Vertigo, Indian Academy of Neurology

29. Vestibular Rehabilitation (VR)
Should be started from day 1
Defined as a form of physical therapy recommended for vertigo which
uses specialized exercises to regain gaze and gait stabilization.
Singly or in combination with pharmacological treatment has proved
useful for managing vestibular or central balance dysfunction
Panagariya A, Dubey P Guidelines on Vertigo, Indian Academy of Neurology

30. In BPPV
Canal repositioning maneuver is the mainstay of
management of BPPV, such as:
◦ Epley’s maneuver and the Semont’s maneuver
◦ The Brandt-Daroff ’s exercises
◦ Log-roll exercises
Panagariya A, Dubey P Guidelines on Vertigo, Indian Academy of Neurology

31. Pharmacotherapy
Anti-vertigo drugs, mainly to provide symptomatic relief and
not for a curative treatment
Vestibular Suppressants to be discontinued within 1 to 3
days1
Suppressants current recommendation is < 24hrs2
1. Lacour M., Restoration of vestibular function: basic aspects and practical advances for rehabilitation. Curr Med Res Opin 2006; 22:1651-59
2. Baloh RW, Kerber KA. Clinical Neurophysiology of the vestibular system. Fourth ed. New York: Oxford University Press, 2011.

32. Betahistine – Dose & Duration
Personalized doses – vestibular compensation varies tremendously between patients
as it is a function of neuroplastic adaptation
Betahistine – Dose and Duration dependent efficacy (Alcocer et al 2015)
IAN recommends 48-72mg/day as a reasonable dose to treat sub acute vertigo
Betahistine 48mg daily for 3-6 months is an effective and safe treatment for Ménière’s
disease and different types of peripheral vertigo. (Alcocer et al 2015)
Use of “higher dose” (48mg TID) proven to be more effective in reducing vertigo
attacks compared to “lower dose” (16mg or 24mg TID) (Strupp et al., 2008)
1. Kirtane MV, Biswas A, Guidelines on Vertigo, Indian Academy of Neurology 2. Lacour M. Curr Med Res Opin 2006; 22:1651-59 3. Strupp et al. Acta Oto-Laryngologica
2008; 1-5. 4. Alcocer et al. Acta Otolaryngol. 2015 Aug 6:1-7.

33. Commonly used medications
Kirtane MV, Biswas A, Guidelines on Vertigo, Indian Academy of Neurology

34. Management of Acute Vertigo
Providing symptomatic relief is important, to reduce anxiety and morbidity
Anti-vertigo drugs are recommended for 1-3 days
Detailed examination is required
Antiemetic (Dimenhydrinate, Prochlorperazine etc) are prudent to use for 1-3 days
Once acute symptoms subside, put the patient on a non-CNS depressant drug like
Betahistine at a dose of 48–72 mg
Put the patient on vestibular exercises right from the first or second day
Kirtane MV, Biswas A, Guidelines on Vertigo, Indian Academy of Neurology

35. Concerns in Management
Use of combinations of anti histamine with histamine analogues
Usage of drugs in sub-therapeutic dosage
Tapering off of anti vertigo drugs
Long-term use of anti vertigo drugs without establishing a definitive
diagnosis
Kirtane MV, Biswas A, Guidelines on Vertigo, Indian Academy of Neurology

36. Case 1:
A 41 year old male with recent vertigo
24 hours in duration and hearing loss in right ear
following upper respiratory infection.

37. Case 2:
A 35 year old female with 2 year history
of monthly intense vertigo with duration
of 2-3 hours.No auditory symptoms. But
has lateralised moderate headache,as
well as light and sound sensitivity.

38. Case 3:
A 72 year old male with 2 month history of intense
vertigo provoked with turning to his right side in
bed.Duration is less than one minute but patient
becomes nauseated.