Managing vertigo in general practice

The aetiology, diagnosis and management of vertigo in primary care, by GP Dr Tillmann Jacobi.

A physical examination should include pulse and BP readings, as well as otoscopy and check for nystagmus (Photograph: SPL)
A physical examination should include pulse and BP readings, as well as otoscopy and check for nystagmus (Photograph: SPL)

Vertigo or dizziness is a very common complaint and affects many individuals at least temporarily at some point during their lifetime. Patients and healthcare professionals often use the terms dizziness and vertigo interchangeably to describe symptoms of imbalance, presyncope, visual disturbance, nausea and light-headedness.

Strictly speaking, the term vertigo should be reserved for rotational dizziness with an illusion or hallucination of movement, either of the surroundings or of the patient themselves.

1. Aetiology

In about 40% of vertigo, the problem lies in the peripheral vestibular system. Typical conditions include benign paroxysmal positioning vertigo (BPPV), vestibular neuronitis (without hearing loss), labyrinthitis (with hearing loss) or Meniere's disease (triad of rotational vertigo, fluctuating low-pitch hearing loss and tinnitus, usually only unilateral).

The exact mechanisms and reasons for developing vertigo due to these conditions are still not fully clear, although a combination of localised infectious or inflammatory processes seems to result in mechanical dysfunction in the labyrinth.

Disruptions in the central nervous system (15%), namely the brain stem, or psychological or psychiatric conflicts (10%), as well as cardiovascular, visual, proprioceptive and other systemic conditions can cause vertigo.

In elderly patients multi-system dizziness or unsteadiness is widespread and typically due to various combinations of medication side-effects, musculoskeletal conditions, visual decline, cardiovascular disease or neuropathies.

2. Differential diagnoses

The most likely differential diagnoses for vertigo due to vestibular causes are migraine, benign vasovagal syncopes, cardiac syncopes due to arrhythmias (not benign), hyperventilation and systemic neurological conditions. Vertigo as the first or only presenting symptom of a brain tumour is very rare.

3. Assessment

The key to successful assessment is to ask the patient to describe the exact experience and duration of their sensation, the circumstances at the time of the initial onset, any consistent triggers (for example, turning in bed, a hint for possible BPPV) and any additional symptoms including nausea, vomiting, headaches or hearing problems.

Nausea and vomiting tend to be more severe in peripheral than in central vertigo, whereas nystagmus is more common in central problems.

A review of current medication is important to identify possible side-effects or interactions, especially if there have been changes recently.

The minimum physical examination should include pulse and BP readings (sitting and standing), otoscopy, a check for nystagmus, the Hallpike manoeuvre and the Romberg test. The Hallpike manoeuvre will typically provoke dizziness and show a geotropic upbeat torsional nystagmus in cases of BPPV.

A referral for an audiogram is important in persistent cases. Also, consider a general ENT opinion for caloric testing and appropriate radiology to exclude other possible underlying causes, even if they may be benign (for example, acoustic neuroma).

Key Points
  • Dizziness is more common than true vertigo.
  • It is essential to take a specific history and undertake a focused examination to reach a meaningful working diagnosis, and to identify potentially significant conditions.
  • Treatment is often mostly supportive and aimed at reducing the disruption caused by the associated symptoms.
  • The outcomes of short-term vertigo are normally good, but long-term symptoms can have a significant impact on the patient's physical, psychological and social functioning.

4. Management

Many problems with acute vertigo will resolve with time alone. However, medication may reduce the often highly disruptive element of vertigo and associated symptoms such as nausea and vomiting.

Antihistamines (for example, cinnarizine) or phenothiazines (for example, prochlorperazine) are most useful. However, prolonged use may prevent or slow down the normal recovery process.

BPPV tends not to improve with medication but can respond very well to the Epley manoeuvre. Occasionally a second treatment after one week is required. Patients with recurrent episodes of BPPV can do this themselves; there are good free instructional videos available online.

Persistent vertigo may benefit from vestibular rehabilitation, physiotherapists or a falls prevention team. The outcomes of this are often good provided an adequate skill mix is available. Relaxation techniques and psychological support can be important if there is concurrent anxiety.

Surgical options, such as gentamicin injections, insertion of grommets or even total labyrinthectomy, are rarely used as they have a high risk of leading to permanent hearing loss. However, they can be effective, particularly for severe, persistent Meniere's disease.

5. Referral

A referral to the respective specialty is indicated where there is any objective or new abnormal cardiovascular or neurological finding, any suggestion of head or spinal injury, barotrauma or metabolic conditions including poisoning.

Any dizziness lasting beyond four weeks (in cases of BPPV, six months) could benefit from a second opinion. Meniere's disease can lead to progressive hearing loss if not managed and monitored carefully; therefore suspected cases should be referred.

Patients with persistent unilateral symptoms or a previous history of middle ear conditions will need a specialist review as well.

Reflect on this article and add notes to your CPD Organiser on MIMS Learning

  • Dr Jacobi is a GP in York

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