This presentation is meant for giving a comprehensive approach to a patient of vertigo. Hope, this will be helpful for general practitioners.

1. APROACH TO
VERTIGO
DR PURNENDU MUKHERJEE

2. HISTORY
• Is it really vertigo?
• What are the triggers?
• Episodic or persistent?
• Associated Headache, vomiting, tinnitus?
• Preceding URTI?
• Medication history

3. Key aspects of the vestibular history (BPPV = benign paroxysmal positional vertigo; URTI = upper respiratory tract
infection)

4. TRIGGERS
• Paroxysmal positional vertigo may be due to BPPV or, rarely, central positional causes
• Recurrent spontaneous attacks of vertigo over several years are often due to
migrainous vertigo or Ménière’s disease.
• Acute persisting vertigo may be caused by vestibular neuritis or posterior fossa stroke.
• Very frequent short-lived spells of dizziness or imbalance might be due to vestibular
paroxysmia or superior canal dehiscence syndrome.
• Postural imbalance without other neurological symptoms may, for example,
commonly be secondary to chronic subjective dizziness or bilateral vestibulopathy
following gentamicin toxicity.

5. CLINICAL EXAMINATION
• BP – may be high in ischemic infarct
• Romberg test
• Nystagmus – Spontaneous, Gaze evoked and Dix-hallpike
• Smooth pursuit test
• Head thrust test
• Cerebellar signs

6. ROMBERG TEST
• It is a test for sensory inputs of balance
• The exam is based on the premise that a
person requires at least two of the three
following senses to maintain balance while
standing
1. Propioception
2. Vestibular function
3. Vision
• If a patient is ataxic and Romberg's test is not
positive, it suggests that ataxia
is cerebellar in nature

7. (Nystagmography – cannot be performed in
OPD)

8. NYSTAGMUS
• Alexander’s law regarding unilateral vestibular nystagmus
1. Jerky nystagmus with direction(fast component) towards healthy ear
2. Nystagmus disease increases in intensity when gazing towards heathy ear
3. Spontaneous nystagmus with central gaze is augmented when vision is
denied(i.e. Suppression with visual fixation by light, evident on electrographic
testing)
• A horizontal nystagmus due to peripheral vestibular imbalance remains horizontal
on upward and downward gaze.
• In Cerebellar infarct, horizontal jerky nystagmus seen with direction towards
affected side

9. SMOOTH PURSUIT
To examine smooth pursuit movement, the patient is asked to follow the target as it is moved
in an arc

10. DIX-HALLPIKE AND EPLEY

11. HEAD THRUST TEST(VOR)
In the first-ever attack of acute spontaneous vertigo, a normal head impulse test raises concern of a
cerebellar infarct

12. INVESTIGATIONS
• PTA when vestibular lesion is suspected
(If normal in the setting of episodic vertigo, one might consider migraine rather
than Ménière’s disease)
• CT scan or MRI if central lesion is suspected

13. SUMMARY
• BPPV – Episodic, Dix hallpike +ve
• Ménière’s disease – Episodic, tinnitus, deafness
• Vestibular Migraine – Episodic, (+/-)headache
• Vestibular neuronitis – 1st time, persists hours to days, preceding URTI, Smooth
pursuit present, head thrust impaired, Romberg +ve
• Cerebellar infarct – 1st time, persists hours to days, Smooth pursuit absent, head
thrust intact, Romberg -ve but patient ataxic
PTA
Rising curve
Normal

14. THANK YOU