Vertigo overview

Vertigo Microchapters
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Patient Information
Overview
Historical Perspective
Classification
Pathophysiology
Causes
Differentiating Vertigo from other Diseases
Epidemiology and Demographics
Risk Factors
Screening
Natural History, Complications and Prognosis
Diagnosis
Diagnostic Study of Choice
History and Symptoms
Physical Examination
Laboratory Findings
Electrocardiogram
X-ray
Echocardiography and Ultrasound
CT
MRI
Other Imaging Findings
Other Diagnostic Studies
Treatment
Medical Therapy
Surgery
Primary Prevention
Secondary Prevention
Cost-Effectiveness of Therapy
Future or Investigational Therapies
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Zehra Malik, M.B.B.S[2]

Overview

Vertigo is identified as 'room spinning around'. It is a type of dizziness. Presyncope, lightheadedness and disequilibrium are other types of dizziness and should be ruled out. The cause of vertigo can be peripheral or central in origin. In peripheral vertigo, dysfunction is in the vestibular system which includes the vestibule (utricle and saccule), semicircular canals, and the vestibular nerve. Central etiologies of vertigo usually originates from the brainstem or cerebellum. Most common causes of vertigo to appear in primary-care are benign paroxysmal positional vertigo, acute vestibular neuronitis, and Ménière’s disease. Best approach to diagnose vertigo etiology is to obtain a complete history paired with a focal examination including assessment of cranial nerves, nystagmus, sensorineural hearing loss (Rinne or Webers test), otoscopic exam of ear canal and tympanic membrane, HINTS (cover/uncover test), Dix-Hallpike maneuver and/or Hennebert’s sign. Acute/severe attacks of vertigo may subside in a day or two after brainstem compensation. Supportive therapy includes bed rest, antihistamine, antiemetic (prochlorperazine, metoclopramide) to relief the symptom. These drugs should not be used for a long period of time as it may delay the compensatory mechanism in the brainstem and result in the prolongation of vertigo symptom.Treating the underlying cause is the definitive treatment of vertigo.

Historical Perspective

Vertigo is derived from the Latin words vertigin and vertere which means "a whirling or spinning movement," and "to turn", respectively.

Classification

Vertigo is classified on the basis of the location of dysfunction into:

• • Peripheral: Lesion in the inner ear or vestibulocochlear nerve.
  • Central: Lesion in brainstem or cerebellum.
• It can also be classified on the basis of its time course or duration:
  • Lasting a day or longer
  • Lasting minutes to hours
  • Lasting seconds

Pathophysiology

• Disruption in the vestibular system results in vertigo. The region of disruption could be peripheral (labyrinth, vestibular nerve) or central (brainstem, cerebellum).
• Vestibulo-ocular reflex is responsible for stabilizing gaze during head movement, it is controlled by six neurotransmitters, which are glutamate, acetylcholine, GABA, dopamine, histamine and norepinephrine.

Causes

• Common causes of vertigo:
  • Peripheral: Benign paroxysmal positional vertigo (BPPV), Ménière's disease, acute labyrinthitis, vestibular neuritis, Herpes zoster oticus(Ramsay Hunt syndrome).
  • Central: Ischemic/hemorrhagic stroke in the cerebellum or brainstem, tumor in cerebellopontine angle, vestibular migraine.
  • Drug induced
  • Psychological Vertigo

Differentiating Vertigo from other Diseases

• Vertigo is one of the four type of dizziness, therefore it must be differentiated from other forms of dizziness, presyncope, lightheadedness and disequilibrium.

Epidemiology and Demographics

• Among the patient who presents with dizziness in the primary care setting, fifty-four percent have vertigo upon investigation.
• Benign paroxysmal positional vertigo, acute vestibular neuronitis, and Ménière’s disease account for ninety-three percent of patients diagnosed with true vertigo in a primary care setting.

Risk Factors

• There are no established risk factors for vertigo, as it is a symptom of an underlying disease.
• However, vertigo can be prevented in some cases by controlling risk factors for the underlying cause.

Screening

• There is insufficient evidence to recommend routine screening for vertigo.

Diagnosis

Diagnostic Study of Choice

• There are no established criteria for the diagnosis of vertigo.
• Best approach to diagnose vertigo etiology is to obtain a complete history paired with a focal examination.

History and Symptoms

• It is important to differentiate between other causes of dizziness before evaluating for the cause of vertigo.
• True vertigo is described as the room spinning around the patient.
• Once true vertigo is established next step is to identify if the origin of dysfunction is central or peripheral.
• Detailed investigation of time course of vertigo and associated signs and symptoms aid in identifying the cause of vertigo.

Physical Examination

• Physical examination of patients experiencing vertigo should include assessment of cranial nerves, nystagmus, sensorineural hearing loss (Rinne or Webers test), otoscopic exam of the ear canal and tympanic membrane, HINTS (cover/uncover test), Dix-Hallpike maneuver, and/or Hennebert’s sign.

Laboratory Findings

• There are no diagnostic laboratory findings associated with vertigo.

Electrocardiogram

• There are no ECG findings associated with vertigo.
• ECG monitoring may be indicated if the cause of dizziness is uncertain.

X-ray

• There are no x-ray findings associated with vertigo.

Echocardiography or Ultrasound

• There are no echocardiography/ultrasound findings associated with vertigo.

CT scan

• CT scan is not the first-line imaging preferred to determine the underlying cause of central vertigo.
• If MRI is contraindicated then a thin cut CT scan can be used.

MRI

• An MRI is the first-line imaging if the cause of vertigo is suspected to be central in origin.
• MRI is superior to a CT scan due to its ability to visualize the posterior fossa.

Other Imaging Findings

• There are no other imaging findings associated with vertigo.
• However, some underlying cause may benefit from electronystagmography or electroencephalogram.
• Further imaging should be conducted according to the diagnostic requirements of the etiology behind the symptom of vertigo.

Other Diagnostic Studies

• There are no other diagnostic studies associated with vertigo. However, the causes of vertigo should be evaluated further according to its diagnostic protocol.

Treatment

Medical Therapy

• Acute/severe attacks of vertigo may subside in a day or two after brainstem compensation.
• Supportive therapy includes bed rest, antihistamine, antiemetic (prochlorperazine, metoclopramide) to relief the symptom.
• Antihistamine (meclizine,betahistine,dimenhydrinate), antiemetic, anticholinergic (scopolamine) and benzodiazepines (diazepam,lorazepam) are the common medications used to treat vertigo as a symptom.
• These drugs should not be used for a long period of time as it may delay the compensatory mechanism in the brainstem and result in the prolongation of vertigo symptom.
• Some patients may be a candidate for vestibular rehabilitation.
• Treating the underlying cause is the definitive treatment of vertigo

Surgery

• For the majority of underlying causes of vertigo, the mainstay of treatment is medical therapy. Surgery is usually reserved for patients with either tumor-associated vertigo, cholesteatoma, and/or when it does not respond to multiple medical therapies.

Primary Prevention

There are no established measures for the primary prevention of vertigo, as it occurs as a symptom of underlying pathology. In some diseases controlling risk factors or triggering, factors can prevent the disease hence preventing the symptoms.

Secondary Prevention

Effective measures for the secondary prevention of vertigo include optimal treatment of the underlying etiology.