NE
Neurology

A Practical Approach to the Patient with Vertigo

February 07, 2014.
Andrew K. Oh, MD,

Educational Objectives

The goal of this program is to improve the diagnosis and treatment of vertigo. After hearing and assimilating this program, the clinician will be better able to:

1. Recognize the 3 common presentations of vertigo.

2. Differentiate between transient ischemic attacks, Meniere disease, and vestibular migraine.

3. Diagnose and treat benign paroxysmal positional vertigo.

Summary

Definition of symptoms: first step in management; prevalence of dizziness and vertigo increases with age, and explanation of symptoms possibly more difficult for older patients (may have cognitive impairment); possible meanings of “dizziness” — include lightheadedness on standing, feeling off balance when walking, or sensation of “room spinning”; ask patients to explain their dizziness with open-ended question (eg, “What do you mean by dizziness? Can you explain it to me?”); if response remains vague, context, timing, and duration of dizziness can provide clues (as important as description of quality of dizziness); if patient has sensation of spinning or turning, term vertigo used; vertigo — illusion of movement of environment, usually spinning or turning; term often used inappropriately; differentiation from symptoms of unsteady gait or disequilibrium important; patients prone to migraine may have dizziness when moving, ie, hypersensitivity to normal motion

Vertigo: indicates imbalance in vestibular system (peripheral or central); always acute (lasts seconds to days, but not weeks to years); brief episodes may recur over long periods of time; patient with occasional attacks of benign paroxysmal positional vertigo (BPPV) over period of, eg, 5 yr, may incorrectly consider condition chronic; with true vertigo, compensation occurs and spinning stops; common in general population (prevalence 5% over 12 mo; rates among patients with depression and substance abuse also in this range)

Three common presentations of vertigo: single attack of prolonged vertigo — new onset, without previous history; attack persists for hours to days; recurrent attacks of spontaneous vertigo — usually recur over long period of time; patient has experienced vertigo previously; vertigo not associated with changes in position or posture; ask patient about activities during attack; recurrent attacks of positionally triggered vertigo — assumption of position triggers attack

Single attack of prolonged vertigo: patients often present to emergency department (ED) with severe vomiting; condition potentially very serious; patients who present to neurologist may be sent to ED for palliative treatment and diagnostic imaging; classically caused by vestibular neuritis (benign); serious causes include brainstem and cerebellar stroke

Vestibular neuritis: caused by unilateral peripheral vestibular lesion; vestibular system maintains balance and stabilizes vision during movement of head; loss of function on one side causes nausea, continuous prolonged spinning sensation, and vomiting, because other side remains active and brain interprets impulses as turning; patients do not want to move (may therefore be confused with positional vertigo), but immobility does not stop spinning; spontaneous nystagmus — key feature; usually jerk nystagmus (involuntary movement of eyes, with fast and slow phases); can be observed with patient looking straight ahead in upright position; beating mostly horizontal and unidirectional (eyes beat quickly to unaffected side, and slowly to affected side); direction of fast phase independent of direction of gaze (although possibly more subtle when looking to affected side); minor torsional component possible; other clinical features — results of neurologic examination normal; vascular and other risk factors for stroke generally absent

Stroke: vertigo with associated neurologic symptoms, eg, slurred speech, incoordination, numbness or weakness (especially one-sided), visual loss or distortions, or field deficits, suggests cerebellar or brainstem stroke; vomiting often not as severe as with vestibular neuritis; patients with cerebellar infarct generally unable to walk; nystagmus generally direction changing, vertical, or gaze evoked with changes in direction; evaluation should include computed tomography to rule out hemorrhage and magnetic resonance imaging (MRI) to rule out infarct

Recurrent attacks of spontaneous vertigo: natural history available; usually not life threatening; main causes include transient ischemic attacks (TIAs), Meniere disease (rare), and vestibular migraine (very common)

TIAs: do not commonly present as isolated vertigo; vertigo usually accompanied by other neurologic symptoms, eg, slurred speech, numbness, weakness; however, 1 or 2 short episodes of isolated vertigo can precede stroke; consider TIA if episodes recent in onset, shorter in duration (eg, 5 min), and accompanied by other neurologic symptoms; hearing loss possible with vertebrobasilar TIAs because blood supply to brainstem shared with that to inner ear (anterior-inferior cerebellar artery [branch of basilar artery])

Meniere disease: often incorrectly diagnosed; one-sided ear symptoms often accompany vertigo attacks, eg, fullness or pressure in ear, hearing loss, tinnitus; one-sided low-frequency hearing loss considered hallmark

Vestibular migraine: also called migraine-associated vertigo, migrainous vertigo, vertiginous migraine, benign recurrent vertigo, or benign paroxysmal vertigo of childhood (characterized by cyclic vomiting); migraine considered condition with various symptoms that can include headache; ≈25% of patients who have had migraine headaches have also experienced recurrent vertigo during lifetime; prevalence of migraine ≈12%; headaches and vertigo can occur separately; attacks of vertigo occur over months to years; can be sole manifestation of migraine; no hearing loss or neurologic deficits present; differentiation from Meniere disease — vertigo attacks may be similar; Meniere disease associated with unilateral otologic symptoms and persistent hearing loss

Recurrent attacks of positional vertigo: benign paroxysmal positional vertigo (BPPV) — easily diagnosed and treated; caused by crystals in inner ear; symptoms nearly always associated with bed (ie, bed dizziness); provoked by lying down, rolling over, or getting out of bed; also caused by head movements in pitch (sagittal) plane; most cases involve posterior semicircular canal (vertical); also called “top-shelf vertigo”; always ask about association of symptoms with bed; orthostatic hypotension — provoked by rising from sitting or lying position; relieved (not provoked, as with BPPV) by lying down

Benign paroxysmal positional vertigo: common; prevalence ≈1.6% over 12 mo; often, diagnosis delayed and no or inadequate therapy provided

Diagnosis: Dix-Hallpike test — patient sits near head of table; stand to side and turn patient’s head to face clinician (at ≈45°); hold patient’s head on both sides and maintain head position while patient lies down with head hanging back (at ≈30°°) over edge of table (patient may hold onto physician for support); look for nystagmus after latency of ≤30 sec; type of nystagmus depends on position; if head hanging and turned to right and BPPV right-sided, eyes beat to right (upbeating and torsional); if BPPV left-sided and head hanging turned to left, eyes beat to left; test positive for BPPV when nystagmus present; perform test on asymptomatic side first (as determined by patient’s description of symptoms); after nystagmus observed on positive side, proceed directly to Epley maneuver

Treatment: Epley maneuver — wait for nystagmus to end; roll head (while still hanging) to opposite side; have patient roll onto shoulder with nose pointing down (may provoke more vertigo); after several seconds, move patient quickly to sitting position; cure achieved in >85% of cases; repeat Dix-Hallpike test and Epley maneuver on symptomatic side; instruct patient to sleep with head slightly elevated for several nights to prevent movement of particles back into posterior semicircular canal

Questions and answers: timing of imaging for patient presenting to ED with acute-onset vertigo — depends on presentation; speaker orders imaging if neurologic symptoms or signs present, or nystagmus anything other than that typical of vestibular neuritis; treatment of dizzy patient with normal neurologic examination and recent history of cold — when presentation includes, eg, serous or opaque fluid behind tympanic membrane, antibiotics often considered because labyrinthitis suspected; however, true bacterial labyrinthitis rare and accompanied by fever, purulent discharge, very severe vertigo, and hearing loss (due to proximity of vestibular system to cochlea); with vestibular neuritis, virus attacks vestibular nerve but usually does not affect cochlear nerve

Readings

Disclosures

In adherence to ACCME Standards for Commercial Support, Audio-Digest requires all faculty and members of the planning committee to disclose relevant financial relationships within the past 12 months that might create any personal conflicts of interest. Any identified conflicts were resolved to ensure that this educational activity promotes quality in health care and not a proprietary business or commercial interest. For this program, members of the faculty and planning committee reported nothing to disclose.

Acknowledgements

Dr. Oh spoke at Neurology Update 2013, held May 10, 2013, in Sacramento, CA, and sponsored by the University of California, Davis, School of Medicine (to learn more about CME programs sponsored by the UC Davis School of Medicine, please visit www.ucd.edu). The Audio-Digest Foundation thanks Dr. Oh and the UC Davis School of Medicine for their cooperation in the production of this program.

CME/CE INFO

Accreditation:

The Audio- Digest Foundation is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The Audio- Digest Foundation designates this enduring material for a maximum of 0 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Audio Digest Foundation is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's (ANCC's) Commission on Accreditation. Audio Digest Foundation designates this activity for 0 CE contact hours.

Lecture ID:

NE050301

Expiration:

This CME course qualifies for AMA PRA Category 1 Credits™ for 3 years from the date of publication.

Instructions:

To earn CME/CE credit for this course, you must complete all the following components in the order recommended: (1) Review introductory course content, including Educational Objectives and Faculty/Planner Disclosures; (2) Listen to the audio program and review accompanying learning materials; (3) Complete posttest (only after completing Step 2) and earn a passing score of at least 80%. Taking the course Pretest and completing the Evaluation Survey are strongly recommended (but not mandatory) components of completing this CME/CE course.

Estimated time to complete this CME/CE course:

Approximately 2x the length of the recorded lecture to account for time spent studying accompanying learning materials and completing tests.

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