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BASICS

  • Vertigo: perceived motion without actual movement; a disturbance in spatial orientation.
  • Symptom, not disease; caused by peripheral or central disorders.
  • Described as "room spinning."
  • One of four types of dizziness: vertigo, presyncope, lightheadedness, disequilibrium.

EPIDEMIOLOGY

  • 4 million US ED visits/year for vertigo/dizziness; only 15% have serious underlying conditions.

  • Females have 3x higher rates of vertiginous migraine.
  • BPPV more common in 50-70 years age group.
  • Medications implicated in 25% of cases.

ETIOLOGY AND PATHOPHYSIOLOGY

  • Peripheral causes (majority): vestibular neuritis, BPPV (posterior canal 85-95%, lateral canal 5-15%), Ménière disease, otosclerosis, labyrinthitis, cholesteatoma.
  • Central causes: cerebellar tumor, stroke, migraine, vestibular ischemia.
  • Other: drug-induced, trauma, psychosocial stress.

RISK FACTORS

  • Migraine history.
  • Cardiovascular disease (CVD) or risk factors.
  • Ototoxic medications.
  • Trauma/barotrauma.
  • Perilymphatic fistula.
  • Heavy weight-bearing.
  • Psychosocial stress, depression.
  • Toxin exposure.

GENERAL PREVENTION

  • Motion sickness prevention with anticholinergics (e.g., scopolamine).

DIAGNOSIS

History

  • Assess medication use and vestibular history.
  • Use TiTrATE framework (Timing, Triggers, and Targeted Exam).
  • Timing: episodic (seconds to days) vs continuous (days to weeks).
  • Triggers: positional changes suggest BPPV; standing up suggests orthostatic hypotension; migraine or psychiatric history should be considered.
  • Beware CNS symptoms or focal deficits suggesting central cause.

Physical Exam

  • Cardiovascular: check orthostatic BP in episodic cases.
  • HEENT: inspect ears for trauma or pathology; perform hearing tests.
  • Neurologic: assess nystagmus, perform Dix-Hallpike and HINTS exam for acute vestibular syndrome.
  • Vertical nystagmus suggests central cause.
  • Dix-Hallpike: positive transient horizontal nystagmus indicates BPPV.
  • Lateral canal BPPV: test with log roll maneuver.
  • HINTS: Head-Impulse, Nystagmus, Test of Skew; helps differentiate central vs peripheral vertigo.
  • Avoid Dix-Hallpike if continuous vertigo and HINTS indicated.

DIFFERENTIAL DIAGNOSIS

  • BPPV (episodic, triggered).
  • Orthostatic hypotension.
  • Ménière disease (episodic, sensorineural hearing loss).
  • Vestibular migraine.
  • Central vestibular causes: stroke, tumor.
  • Psychiatric causes.
  • Medication/toxin effects.
  • Cardiovascular disease.
  • Hypoglycemia.
  • Degenerative neurologic diseases.
  • Peripheral neuropathies.

DIAGNOSTIC TESTS & INTERPRETATION

  • Labs generally not necessary unless abnormal neuro exam.
  • MRI (STAT) if central cause suspected.
  • ENT referral for suspected Ménière disease for electronystagmography.
  • Audiometry for acoustic neuroma or Ménière disease suspicion.

TREATMENT

General

  • Treat underlying cause.
  • Stop causative medications.

BPPV

  • Epley maneuver recommended.
  • Vestibular rehabilitation exercises.
  • Vestibular suppressants and antiemetics generally avoided, except short-term nausea control.

Ménière Disease

  • Low-salt diet (<1-2 g/day).
  • Diuretics (hydrochlorothiazide).
  • Treat perilymphatic hydrops.

Vestibular Migraine

  • Lifestyle and dietary modifications.
  • Migraine prophylactic medications.

Psychiatric

  • SSRIs preferred for anxiety-related vertigo.

Medications

  • Meclizine 12.5-50 mg PO q4-8h (use caution in elderly).
  • Dimenhydrinate 50 mg PO q6h.
  • Prochlorperazine 5-10 mg PO/IM q6-8h.
  • Metoclopramide 5-10 mg PO/IV q6h.

ISSUES FOR REFERRAL

  • Atypical or refractory cases.
  • Need for vestibular rehab therapy.
  • Neurologist or otolaryngologist consult.

ADDITIONAL THERAPIES

  • Epley or Semont maneuvers for BPPV.
  • Barbecue roll or Gufoni maneuvers for lateral canal BPPV.
  • Vestibular rehab therapy.

ONGOING CARE

  • Follow-up in 1-2 weeks for symptom resolution and medication side effects.
  • Encourage balance exercises for recovery.

DIET

  • Salt restriction for Ménière disease.

PATIENT EDUCATION

  • Avoid triggers (e.g., caffeine, alcohol).
  • Instructional videos for repositioning maneuvers available.

PROGNOSIS

  • Depends on underlying cause and treatment response.

COMPLICATIONS

  • Anxiety, depression.
  • Disability and fall-related injuries.

REFERENCES

  1. Rogers TS, Noel MA, Garcia B. Dizziness: evaluation and management. Am Fam Physician. 2023;107(5):514-523.
  2. Muncie HL, Sirmans SM, James E. Dizziness: approach to evaluation and management. Am Fam Physician. 2017;95(3):154-162.
  3. Newman-Toker DE, Edlow JA. TiTrATE: a novel, evidence-based approach to diagnosing acute dizziness and vertigo. Neurol Clin. 2015;33(3):577-599.

ICD10

  • R42 Dizziness and giddiness
  • H81.10 Benign paroxysmal vertigo, unspecified ear
  • H81.49 Vertigo of central origin, unspecified

Clinical Pearls

  • Medication review is essential to identify iatrogenic causes.
  • Use TiTrATE approach to assess dizziness and vertigo.
  • Acute, spontaneous vertigo with normal head impulse test and direction-changing nystagmus (HINTS positive) strongly suggests central cause.
  • Epley maneuver is recommended for BPPV treatment; avoid vestibular suppressants for BPPV.
  • Do not perform Dix-Hallpike if HINTS exam is warranted.
  • Ambulate patient before discharge to assess safety.