Vertigo¶
Background¶
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Clinical Presentation
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Sensation of the room spinning or moving, or themselves spinning or moving
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Must distinguish from orthostasis/presyncope via history
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Causes: most easily differentiated based on chronicity and triggers rather than description of symptoms
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BPPV - short duration, very positional, classically nystagmus is horizontal and torsional with the posterior canal being most commonly involved
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Vestibular neuronitis/labyrinthitis – typically follows URI or ear infections; often self-limited, but can be severe/prolonged, in which case it is treated with steroids
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Menière’s Disease – tinnitus and low range frequency hearing loss, generally progressive and treated with diuretics, meclizine and sometimes surgeries or intratympanic injections
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Endolymphatic Leak – usually following trauma or concussive blasts, requires ENT eval and management. Classically a loud sound will cause vertigo and nystagmus
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vertiginous migraine: usual migraine triggers, may have aura. Episodic nature and often positive family hx of migraine or even vertiginous migraine.
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Stroke – sudden onset, ask about vascular risk factors, rare cause of isolated vertigo
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Evaluation/Management¶
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Careful exam of vertigo will be more helpful than random scans, but pt has to be symptomatic for exam to mean anything:
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HINTS Battery – Head Impulse test, Nystagmus pattern, Test of skew
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Central pattern – no corrective saccade, multidirectional nystagmus, skew present
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Peripheral pattern – corrective saccade, unidirectional nystagmus, no skew present
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Dix-Hallpike Test
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Cerebellar testing: FNF, HKS, mirroring, gait
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Outpatient Vestibular function testing with ENT
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Central patterns will need head and vessel imaging (looking for vertebral dissection or basilar clots)
- Often, central vertigo is due to centrally acting medications
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Peripheral causes are varied and often require eval by ENT as an outpatient
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Treatment with anticholinergics like meclizine or scopolamine is often helpful
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Vestibular therapy with OT is also very beneficial