VERTIGO

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VERTIGO

• AYESHA SHAIKH
• PGY2
• EMORY FAMILY MEDICINE
• 09.17.2008

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CASE

• 31,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!

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DIZZINESS

• Vertigo
• Lightheadedness
• Pre syncope
• Dys-equilibrium

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VERTIGO

• FALSE SENSE OF MOTION, usually rotational.
• 2 TYPES
• 1- CENTERAL VESTIBULAR CAUSES
• (Brain stem or cerebellum)
• 2- PERIPHERAL VESTIBULAR CAUSES
• ( Labyrinth or vestibular nerve)

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CAUSES OF VERTIGO

• CENTRAL
• Cerebellopontine angle tumor
• Cerebrovascular disease
• Migraine
• Multiple sclerosis

• PERIPHERAL
• Acute labrynthitis
• Vestibular neuritis
• BPPV
• Cholestotoma
• Meniers disease
• Ostosclerosis
• Perilymphatic fistula

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Causes..

• Drugs
• Alcohol
• Aminoglycosides
• Anticonvulsants
• Antidepressants
• Antihypertensives
• Barbiturates
• Cocaine
• ( Slowly progressive Unilateral/Bilateral)

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History

• Timings
• Duration
• Provoking, aggreviating factors
• Associated symptoms
• Risk factors for Cardiovascular disease
• Q 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)

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Typical Duration of Symptoms for Different
Causes of Vertigo Duration of episode
Suggested 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 one 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) -Vertigo with early acute
vestibular neuritis can last as briefly as two
days or as long as one week or more. Information
from references 3, 6, and 12.
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• Provoking Factors for Different Causes of Vertigo
• Provoking 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
  Ménière's 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

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Associated Symptoms for Different Causes of
Vertigo Symptom Suggested
diagnosis Aural fullness Acoustic
neuroma Ménière's disease Ear or mastoid pain
Acoustic neuroma acute middle ear disease
(e.g., otitis media, herpes zoster
oticus) Facial weakness Acoustic
neuroma herpes zoster oticus Focal neurologic
Cerebellopontine angle tumor
cerebrovascular disease findings)
multiple sclerosis (especially findings
not explained by single neurologic
lesion Headache Acoustic
neuroma migraine Hearing loss
Ménière's disease perilymphatic fistula
acoustic neuroma cholesteatoma
otosclerosis transient
ischemic attack or stroke involving anterior
inferior cerebellar
artery,herpes zoster oticus Imbalance
Acute vestibular neuronitis
(usually moderate) cerebellopontine angle tumor
(usually
severe) Nystagmus Peripheral
or central vertigo Phonophobia, photophobia
Migraine Tinnitus Acute
labyrinthitis acoustic neuroma Ménière's
disease Information from references 1, 6, and 12
through 14.
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Table 5 Causes of Vertigo Associated with
Hearing Loss Diagnosis
Characteristics of hearing
loss Acoustic neuroma Progressive,
unilateral, sensorineural Cholesteatoma
Progressive, unilateral, conductive Herpes
zoster oticus (i.e., Ramsay Hun syndrome)
Subacute to acute onset,
unilateral Ménière's diseases
Sensorineural, initially fluctuating, initially
affecting lower frequencies
later in course progressive,
affecting higher frequencies Otosclerosis
Progressive, conductive Perilymphatic
fistula Progressive, unilateral Transient
ischemic attack or stroke involving anterior
inferior cerebellar artery or internal auditory
artery Sudden onset,
unilateral Information from references 9, 12,
and 13.
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Distinguishing Characteristics of Peripheral vs.
Central Causes of Vertigo Feature
Peripheral vertigo
Central vertigo Nystagmus
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 gaze

Imbalance
Mild to moderate able to walk
Severe unable to stand still or
walk Nausea May be severe

Varies , vomiting Hearing loss, tinnitus
Common
Rare Nonauditory
Rare
Common neurologic
symptoms Latency following provocative
diagnostic Longer (up to 20
seconds)
Shorter (up to 5 seconds) maneuver) Information
from references 14 and 15.
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Physical Exam

• Special attention to head and neck
• Cardiovascular and neurologic symptoms
• Provocative diagnostic tests

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Physical Exam

• Vertical 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 .

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Clues to Distinguish Between Peripheral and
Central Vertigo Clues
Peripheral vertigo
Central vertigo Findings on
Latency of symptoms
None Dix-Hallpike and
nystagmus 2 to 40 seconds maneuver Severity of
vertigo Severe
Mild
Duration of nystagmus Usuallylt 1 minute
Usuallygt1
minute Fatigability
Yes
No Habituation
Yes
No Other findings Postural
instability Able to walk
Falls while
walking
unidirectional instability
severe instability Hearing loss
or tinnitus Can be
present
Usually absent Other neurologic Symptoms
Absent
Usually
present -Response remits spontaneously as
position is maintained. -Attenuation of
response as position repeatedly is
assumed. Information from references 3 and 4.
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Diagnosis

• History
• Physical Exam Orthostatic vital signs, and
  Otoscopic examination,
• Neurologic Exam Dix-Hallpike Maneuver ( central
  vs Peripheral)
• Complete Audiometric Testing for suspected
  Meniers disease
• No LAB testing!
• Brain imaging MRI with contrast for acute
  vertigo and Sensorineural hearing loss, MRA for
  vertebrobasilar circulation

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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)

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• Strength of Recommendation
• Key clinical recommendation
• The canalith repositioning procedure (Epley
  maneuver) is recommended in patients with benign
  paroxysmal positional 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
  vestibular neuronitis. C
• Vestibular exercises are recommended for more
  rapid and complete vestibular compensation in
  patients with acute vestibular neuronitis. B
• Treatment with a low-salt diet and diuretics is
  recommended for patients with Ménière's disease
  and vertigo.B
• Effective treatments for vertiginous migraine
  include migraine prophylaxis (e.g., tricyclic
  antidepressants, beta blockers, calcium channel
  blockers), migraine-abortive medications (e.g.,
  sumatriptan Imitrex), and vestibular
  rehabilitation exercises B
• Selective serotonin reuptake inhibitors can
  relieve vertigo in patients with anxiety
  disorders. Because of side effects, slow
  titration is recommended.B

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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

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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.

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Treatment of Specific Disorders

• 1- BPPV
• (Usually posterior canal Calcium
  Debris)
• MEDS..?
• Head Rotation Maneuvers
• Eply Maneuver
• Contraindication Severe carotid stenosis,
  unstable heart disease, severe neck disease
• Success rate 80 after one treatment, 100 with
  repeated treatments.
• Recurrence rates 15 /year, 20 _at_ 20 months, and
  37 _at_ 60 months.

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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.

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Treatment of specific disorders

• 3-Meniers Disease
• (Distension of Endolymphatic compartment due
  to impaired endolymphatic filtration and
  excretion)
• Low salt diet ( lt 1-2 gm/day)
• Diuretics ( combo HCTZ and Triamterene)
• Surgery in rare cases - ablation of vestibular
  hair cells)

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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.

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6-Migraine Headaches

• Treat Migraine!
• Reduce or eliminate Aspartame, chocolate,
  caffeine and alcohol, Lifestyle changes,
  Vestibular rehabilitation exercises.
• Meds BDZ, TCA, BB, SSRI, CCB, Antiemetics.

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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.

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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.

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Dix-Hallpike Maneuver
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Epley Maneuver
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Internet resources for patient education

• http//www.youtube.com/watch?vhhinu_oU_hM
• http//www.youtube.com/watch?vNQr7MKJBAJY
• http//www.youtube.com/watch?veOuzUi5ckrk

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THANKS !
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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.