Primary evaluation and acute management of vertigo

Sisha Liz Abraham

doi:10.4103/cmi.cmi_11_20

REVIEW ARTICLE

Year : 2020 | Volume : 18 | Issue : 3 | Page : 217-221

Primary evaluation and acute management of vertigo

Sisha Liz Abraham
Department of Surgical Oncology, Cochin Cancer Research Centre, Kochi, Kerala, India

Date of Submission	08-Feb-2020
Date of Decision	09-Feb-2020
Date of Acceptance	04-Mar-2020
Date of Web Publication	10-Jul-2020

Correspondence Address:
Dr. Sisha Liz Abraham
Department of Surgical Oncology, Cochin Cancer Research Centre, Kochi, Kerala
India

Source of Support: None, Conflict of Interest: None

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DOI: 10.4103/cmi.cmi_11_20

Abstract

Vertigo, an illusory movement, arises mostly because of lesions in the peripheral vestibular system (e.g., damage or dysfunction of the labyrinth and vestibular nerve) and occasionally that of central vestibular structures. Patients give various descriptions of vertigo: a head-spinning feeling, swaying, tilting, or an imbalance in walking depending on the location of the lesion. Acute vertigo remains a diagnostic challenge for the physicians due to the wide array of differential diagnosis. It is important to distinguish the central causes of vertigo from its peripheral causes. Benign paroxysmal positional vertigo (BPPV) is one of the most common causes of peripheral vertigo, most commonly attributed to calcium debris within the posterior semicircular canal, known as canalithiasis. Prompt diagnosis by positional testing (e.g., Dix–Hallpike), performing a bedside repositioning maneuver (e.g., Epley) and administering symptomatic therapy helps in providing the quick relief to the highly distressing symptom of vertigo due to BPPV.

Keywords: Benign paroxysmal positional vertigo, Epley maneuver, peripheral vertigo, vertigo

How to cite this article:
Abraham SL. Primary evaluation and acute management of vertigo. Curr Med Issues 2020;18:217-21

How to cite this URL:
Abraham SL. Primary evaluation and acute management of vertigo. Curr Med Issues [serial online] 2020 [cited 2020 Oct 27];18:217-21. Available from: https://www.cmijournal.org/text.asp?2020/18/3/217/289405

Introduction

Vertigo is a symptom of illusory movement (feels as if the person or the objects around them are moving when they are not). It arises because of abnormalities in the peripheral vestibular system (e.g., damage to/dysfunction of the components of labyrinth and vestibular nerve) or from the lesions of the central vestibular structures in the brainstem.^[1],[2],[3] It is associated with significant disability and can be prolonged or intermittent in nature. Vertigo, as a symptom, poses a significant challenge to emergency care physicians as they have to consider a wide array of differential diagnosis in a short span of time and localize the lesion [Table 1]. Hence, a prompt and timely diagnosis is essential to initiate any early intervention that is required.

Table 1: Common causes of central and peripheral vertigo

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Vertigo is a symptom and not a diagnosis. Patients varyingly describe it as a head-spinning feeling, swaying, tilting, or an imbalance in walking depending on the exact site of abnormality.^[4],[5],[6] The most common sensation is a rotatory sensation, though it is not always the case. Vertigo can occur as a single or recurrent episode and may last seconds, hours, or days. Acute vertigo may be associated with nausea and vomiting, which may be significant enough to cause dehydration and electrolyte imbalance. A summary of the clinical features of common forms of acute vertigo is shown in [Table 2].

Table 2: Clinical features of common causes of vertigo^[3]

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The evaluation of a patient with vertigo is shown in [Figure 1].

Figure 1: Evaluation of a patient with vertigo.

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Evaluation: History

A history of the symptoms plays a key role in distinguishing vertigo from the other differentials and in localizing the lesion. Try to obtain an unprompted description of the patient's “dizziness” or “giddiness.” Cardiovascular causes usually lead to presyncope/syncope and neurological causes are accompanied by disequilibrium. Hence, both should be ruled out during the evaluation in emergency care. A good history should include the following:

Time course of events:

Recurrent vertigo of short duration with positional variation suggests benign paroxysmal positional vertigo (BPPV) whereas that of long duration suggests Meniere's disease^[7],[8]
A single episode of vertigo lasting many hours may point to migraine or transient ischemic attack of the brain stem^[9]
Labyrinthitis and vestibular neuronitis are typically associated with the vertigo of prolonged duration over days.^[10],[11]
Aggravating and relieving factors: All types of vertigo become symptomatically worse with the head movement. Most patients prefer to keep their head still in fear of worsening of symptoms. Vertigo aggravated by or provoked with specific head movements or postures is typical of BPPV. History of head trauma should always be sought for the likely possibility of whiplash or that of perilymphatic fistula.^[12] History of vertigo and a recent viral infection suggest the possibility of vestibular neuronitis caused by the inflammation of the eighth cranial nerve^[11]
Associated symptoms: The features of the brain stem involvement such as diplopia, dysarthria, dysphagia, weakness, or numbness suggest vertigo due to a vertebrobasilar stroke. Peripheral vertigo associated with the symptoms such as deafness and tinnitus may point to Meniere's disease. Headache and photophobia are usually associated with migrainous vertigo^[9]
Past medical history: A significant past medical history includes a history of migraine, risk factors for a cerebrovascular accident (diabetes mellitus, hypertension, smoking, etc.), other neurological disorders, status of vision, psychiatric issues, and past history of head trauma. Certain medications (aminoglycosides, cisplatin, and phenytoin) can cause vertigo, and drug history is absolutely essential.^[13]

Evaluation: Examination

It is important to perform a complete otologic and neurologic examination in patients presenting with vertigo.

Nystagmus: It is a rhythmic oscillation of the eyes. The patient with the acute onset of vertigo tends to have nystagmus when the gaze is not fixed. In peripheral vertigo, the fast phase is usually away from the affected side. Peripheral vertigo is characterized by horizontal or torsional or mixed nystagmus, but never vertical. Central vertigo may have any trajectory, but vertical nystagmus strongly suggests a central origin of vertigo
Other neurological signs: A detailed central nervous system examination looking for cranial nerve abnormalities, cerebellar signs, motor or sensory changes, or abnormal reflexes, which would indicate a central cause for vertigo
Tests of hearing: Bedside tests of hearing (Weber and Rinne tests) and an otoscopic examination of the tympanic membrane for evidence acute or chronic otitis media. It should be performed to distinguish the etiology of vertigo
Dix-Hallpike maneuver: The most important cause of vertigo that present as an acute emergency is BPPV. This maneuver is helpful in diagnosing the classical posterior canal BPPV. It should not be performed in patients with a carotid bruit or risk factors for vertebrobasilar insufficiency due to a theoretical risk of precipitating a cerebrovascular accident.^[14],[15] The test is diagnostic for BPPV if positive, but does not rule it out if negative.

Benign Paroxysmal Positional Vertigo

BPPV is one of the most common causes of vertigo presenting in the emergency department. It is a mechanical disorder of the inner ear and is commonly attributed to free-floating debris within the semicircular canal (posterior being the most common), known as canalithiasis.^{[16],[17],[18]} This debris likely represents loose otoconia (calcium carbonate crystals) within the auricular sac. These are normal structures that are displaced from the utricle.

There are three variants:

Posterior canal (prototype/classical) – the most common
Horizontal canal (lateral canal) – the second-most common
Anterior canal (superior canal).

Posterior Canal Benign Paroxysmal Positional Vertigo (Proto-Type/classical)

Recurrent episodes of vertigo lasting 1 min or less. Although individual episodes are brief, these typically recur periodically for weeks to months without therapy. Episodes are provoked by the specific types of head movements, such as looking up while standing or sitting, lying down or getting up from bed, and rolling over in bed. The spells may wax and wane over time. Vertigo may be associated with nausea and at times vomiting.

Examination

Nystagmus is optimally provoked by the Dix–Hallpike or Nylen–Barany maneuver (sensitivity 50%–88%).^[14] Nystagmus is an involuntary movement of the eye characterized by a smooth pursuit eye movement followed by a rapid saccade in the opposite direction of the smooth pursuit eye movement. Dix–Hallpike maneuver is helpful in diagnosing the classical posterior canal BPPV. The test itself may provoke severe vertigo. Premedication with betahistine or dimenhydrinate IM or IV may make the test more tolerable and will not diminish the nystagmus.

Dix-Hallpike maneuver

Instruct the patient to keep their eyes open all the time and look at the examiners face
With the patient sitting, extend the neck and turn to one side
Place the patient supine rapidly, so that the head hangs over the edge of the bed
Keep the patient in this position until 30 s have passed if no nystagmus occurs
The patient should also be queried about the presence of subjective vertigo
Return the patient to upright position, observe for another 30 s for nystagmus, and then repeat the maneuver with the head turned to the other side.

Diagnostic criteria employing the Dix–Hallpike maneuver for posterior canal benign paroxysmal positional vertigo

Nystagmus and vertigo usually appear with a latency of a few seconds and last <60 s
It has a typical trajectory, beating upward and torsionally, with the upper poles of the eyes beating toward the ground with a crescendo-decrescendo pattern
After it stops and the patient sits up, the nystagmus may recur but in the opposite direction
The patient should then have the maneuver repeated to the same side, with each repetition, the intensity and duration of nystagmus will diminish.(nystagmus fatigability)
The side showing the positive test is the side of the lesion.

The clinical practice guideline published by the American Academy of Otolaryngology and Head and Neck Surgery does not include nystagmus fatigability as a diagnostic criterion.^[19] If the patient's history is compatible with BPPV, but the Dix–Hallpike test exhibits no nystagmus or horizontal nystagmus, and the clinician should perform a supine roll test to assess for lateral semicircular canal BPPV.

Supine head roll test (Pagnini-Lempert or Pagnini-McClure Roll test) for lateral canal benign paroxysmal positional vertigo

The patient is made to lie supine with the head in the neutral position, followed by quickly rotating the head 90° to one side
The patient's eyes are observed for nystagmus
Once the nystagmus subsides or if no nystagmus is elicited, the head is then brought back to the straight face up supine position
If any additional nystagmus is elicited, it is allowed to settle and the head is then quickly turned 90° to the opposite side, and the eyes are once again observed for nystagmus.

Lateral semicircular canal BPPV may occur following the performance of the canalith repositioning procedure for an initial diagnosis of posterior semicircular canal BPPV (canal conversion). Hence, clinicians should be aware of lateral semicircular canal BPPV and its diagnosis.^[20]

Acute Management of Benign Paroxysmal Positional Vertigo

The particle repositioning maneuver (Epley maneuver more commonly practiced than Semont maneuver) should be performed for all patients with confirmed posterior canal BPPV. The Epley maneuver for a right side BPPV is shown in [Table 3] and [Figure 2]. This procedure alone provides significant symptom relief in many patients.^[21],[22] Lempert 360 roll maneuver or Gufoni maneuver is performed for lateral canal BPPV.

Table 3: Particle repositioning maneuver (Epley maneuver)

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Figure 2: Epley maneuver. The patient is instructed to lie supine or to left with the head elevated after the procedure and be preferably on bed rest after the procedure for 48 h. The entire sequence is repeated later for residual symptoms. BPPV: Benign paroxysmal positional vertigo

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Oral medications may then be added for additional symptomatic management. The following classes of drugs are effective in suppressing the vestibular system.

Antihistamines: diphenhydramine, dimenhydrinate, cinnarizine, and meclizine
Antiemetics: prochlorperazine, promethazine, ondansetron, and metoclopramide
Benzodiazepines: diazepam, lorazepam, and alprazolam.

Commonly used medications for vertigo

Tablet cinnarizine 25 mg three times a day OR
Tablet betahistine 16 mg three times a day OR
Tablet prochlorperazine 10 mg three times a day OR
Tablet flunarizine 10 mg three times a day OR
Tablet promethazine 25 mg twice a day OR
Syrup diphenhydramine 10–20 ml three times a day.

These drugs are quite effective for acute symptomatic relief of vertigo. Antihistamines are usually used as the first choice for most patients, with sedation being a common side effect. The phenothiazine antiemetics such as prochlorperazine and promethazine are more sedating and hence are reserved for patients with severe vomiting. Benzodiazepines too are quite sedative and are reserved for patients with severe symptoms. The drug of choice in pregnancy is meclizine.^[23]

Conclusion

Acute vertigo remains a diagnostic challenge for emergency physicians due to the wide array of differential diagnosis. It may be categorized as central or peripheral and making the distinction between the two is the most important part of evaluation. A thorough history is important to distinguish vertigo from other forms of giddiness or lightheadedness. Laboratory testing and radiography are not routinely indicated in the workup of patients with vertigo when no other neurologic abnormalities are present. Prompt diagnosis, performing a bedside canalith repositioning maneuver, and administering symptomatic therapy help in quick relief in BPPV which happens to be the most common cause of vertigo.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

1.	Neuhauser HK. Epidemiology of vertigo. Curr Opin Neurol 2007;20:40-6.
2.	Norrving B, Magnusson M, Holtås S. Isolated acute vertigo in the elderly; vestibular or vascular disease? Acta Neurol Scand 1995;91:43-8.
3.	Abhilash KP. Emergency Medicine: Best Practices at CMC. 2^nd ed., Ch. 87, 282. New Delhi: Jaypee Brothers' Medical Publishers; 2019.
4.	Newman-Toker DE, Cannon LM, Stofferahn ME, Rothman RE, Hsieh YH, Zee DS. Imprecision in patient reports of dizziness symptom quality: A cross-sectional study conducted in an acute care setting. Mayo Clin Proc 2007;82:1329-40.
5.	Stanton VA, Hsieh YH, Camargo CA Jr., Edlow JA, Lovett PB, Goldstein JN, et al. Overreliance on symptom quality in diagnosing dizziness: Results of a multicenter survey of emergency physicians. Mayo Clin Proc 2007;82:1319-28.
6.	Nedzelski JM, Barber HO, McIlmoyl L. Diagnoses in a dizziness unit. J Otolaryngol 1986;15:101-4.
7.	Karlberg M, Hall K, Quickert N, Hinson J, Halmagyi GM. What inner ear diseases cause benign paroxysmal positional vertigo? Acta Otolaryngol 2000;120:380-5.
8.	Epley JM. New dimensions of benign paroxysmal positional vertigo. Otolaryngol Head Neck Surg (1979) 1980;88:599-605.
9.	Neuhauser H, Leopold M, von Brevern M, Arnold G, Lempert T. The interrelations of migraine, vertigo, and migrainous vertigo. Neurology 2001;56:436-41.
10.	Schessel DA, Minor LB, Nedzelski J. Meniere's disease and other peripheral vestibular disorders. In: Gaertner RS, Murphy MB, editors. Cummings Otolaryngology Head and Neck Surgery. 4^th ed., Philadelphia: Mosby; 2004. p. 3231-2.
11.	Baloh RW. Clinical practice. Vestibular neuritis. N Engl J Med 2003;348:1027-32.
12.	Black FO, Pesznecker S, Norton T, Fowler L, Lilly DJ, Shupert C, et al. Surgical management of perilymphatic fistulas: A Portland experience. Am J Otol 1992;13:254-62.
13.	Cianfrone G, Pentangelo D, Cianfrone F, Mazzei F, Turchetta R, Orlando MP, et al. Pharmacological drugs inducing ototoxicity, vestibular symptoms and tinnitus: A reasoned and updated guide. Eur Rev Med Pharmacol Sci 2011;15:601-36.
14.	Dix MR, Hallpike CS. The pathology, symptomatology and diagnosis of certain common disorders of the vestibular system. Ann Otol Rhinol Laryngol 1952;61:987-1016.
15.	Hilton MP, Pinder DK. The Epley (canalith repositioning) manoeuvre for benign paroxysmal positional vertigo. Cochrane Database Syst Rev 2014;(12):CD003162.
16.	Brandt T, Steddin S. Current view of the mechanism of benign paroxysmal positioning vertigo: Cupulolithiasis or canalolithiasis? J Vestib Res 1993;3:373-82.
17.	Vannucchi P, Giannoni B, Pagnini P. Treatment of horizontal semicircular canal benign paroxysmal positional vertigo. J Vestib Res 1997;7:1-6.
18.	Parnes LS, Agrawal SK, Atlas J. Diagnosis and management of benign paroxysmal positional vertigo (BPPV). CMAJ 2003;169:681-93.
19.	Bhattacharyya N, Gubbels SP, Schwartz SR, Edlow JA, El-Kashlan H, Fife T, et al. Clinical Practice Guideline: Benign Paroxysmal Positional Vertigo (Update). Otolaryngol Head Neck Surg 2017;156:S1-S47.
20.	White JA, Coale KD, Catalano PJ, Oas JG. Diagnosis and management of lateral semicircular canal benign paroxysmal positional vertigo. Otolaryngol Head Neck Surg 2005;133:278-84.
21.	Helminski JO, Zee DS, Janssen I, Hain TC. Effectiveness of particle repositioning maneuvers in the treatment of benign paroxysmal positional vertigo: A systematic review. Phys Ther 2010;90:663-78.
22.	Strupp M, Cnyrim C, Brandt T. Vertigo and dizziness: Treatment of benign paroxysmal positioning vertigo, vestibular neuritis and Menère's disease. In: Candelise L, editor. Evidence-Based Neurology-Management of Neurological Disorders. Oxford: Blackwell Publishing; 2007. p. 59-69.
23.	Leathem AM. Safety and efficacy of antiemetics used to treat nausea and vomiting in pregnancy. Clin Pharm 1986;5:660-8.