Vertigo

Vertigo

Background

  • Sensation of the room spinning or moving, or themselves spinning or moving
  • Distinguishing between vertigo and orthostasis/presyncope via history is important
    • Ask about triggers, exacerbating factors, duration, if it has happened before
    • Ask about vascular risk factors, as stroke is an uncommon cause of isolated vertigo
    • Presentation based on Cause:
      • BPPV – short duration, very positional, classically nystagmus is horizontal and torsional with the posterior canal being most commonly involved
      • 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
      • Menière’s Disease – tinnitus and low range frequency hearing loss, generally progressive and treated with diuretics, meclizine and sometimes surgeries or intratympanic injections
      • Endolymphatic Leak – usually following trauma or concussive blasts, requires ENT eval and management. Classically a loud sound will cause vertigo and nystagmus
      • Vertigo may also be caused by migraines, possibly without associated headache

 

Evaluation/Management

  • Careful exam of vertigo will be more helpful than random scans, but pt has to be symptomatic for exam to mean anything:    
    • HINTS Battery – head impulse test, nystagmus pattern, test of skew
      • Central pattern – no corrective saccade, multidirectional nystagmus, skew present
      • Peripheral pattern – corrective saccade, unidirectional nystagmus, no skew present
    • Dix-Hallpike Test
    • Cerebellar testing: FNF, HKS, mirroring, gait
  • Central patterns will need head imaging with vessel imaging (looking for vertebral dissection or basilar clots)
    • Often, central vertigo is due to centrally acting medications
  • Peripheral causes are varied and often require eval by ENT as an outpatient
  • Treatment with anticholinergics like meclizine or scopolamine is often helpful
  • Vestibular therapy with OT is also very beneficial
  • Example of HINTS test