Section 1 Presentation and aetiology
Illusions of spinning or rotating are usually interpreted by the GP as symptomatic of a vestibular disorder, particularly if they are accompanied by nausea and demonstrable unsteadiness.
However, possible alternative diagnoses to a vestibular neuritis include serious disorders such as cerebellar stroke, or benign paroxysmal positional vertigo (BPPV), a benign condition that is amenable to immediate treatment.
A comprehensive history is essential but may be difficult to obtain as patients find it difficult to articulate their experiences.
History taking may be hindered because few languages make distinctions between the many manifestations of 'dizziness' (see box). Nevertheless, careful questioning should identify the key features of vestibular vertigo.
Central is the illusion of motion, usually of rotation, in which the patient, or the ground, may be sensed as turning or tilting. This is termed 'vestibular vertigo'. Unsteadiness and nausea, which may proceed to vomiting, are also core features of vertigo.
Manifest nystagmus, which may be present in the acute phase of vertigo, causes the visual disturbance oscillopsia, even when the patient is lying still.
Other non-specific symptoms including faintness, disorientation and detachment may be present. The doctor must therefore focus on assessing whether the core features of vestibular vertigo are indeed present.
The vestibular organ detects head motion and this head motion information is transmitted to different brain regions; for example, to ocular motor regions for stabilisation of gaze during head movements (the vestibular-ocular reflex, VOR); to perceptual regions so that we can sense when we move about; to postural centres to help maintain our balance, and to autonomic centres which adjust BP and respiration to changes in posture.
Abnormal activity in the vestibular system may cause nystagmus via asymmetric VOR activation, dizziness by incorrectly indicating self-motion to perceptual regions, imbalance by affecting vestibulo-spinal pathways, as well as nausea via vestibular-autonomic connections in the brainstem.
Abnormal activity in vestibular pathways may arise peripherally (vestibular neuritis) or centrally (cerebellar stroke), either of which can cause profound vertigo, nausea and vomiting, although gross balance impairment implies central vestibular involvement.
Note: It is always best to record what the patient feels; e.g. 'rocking like a boat' or 'spinning like a merry-go-round'. 'Dizzy' or 'vertigo' without elaboration is not enough.
Section 2 Diagnosis
The most common causes of acute isolated vertigo are BPPV, vestibular neuritis, migraine and stroke. Meniere's disease is the most common cause of acute vertigo with hearing loss.
The textbook history of BPPV is violent spinning dizziness (vertigo) lasting 15 seconds or less and usually precipitated by head movements such as looking up or when bending or lying down.
Ask about dizziness when turning over in bed. Patients who get transient and violent vertigo on turning over in bed will almost certainly have BPPV.
This question eliminates the issue of postural hypotension.
The key sign is positional nystagmus on Hallpike testing (see online demonstration).1 Positional nystagmus can occur with central lesions too, so it is important to know what to look for when performing the test.
Patients with vestibular neuritis develop vertigo sub-acutely (i.e. over several minutes to hours) and there may be a viral-like prodrome.
The vertigo is typically continuous and improves over 24-36 hours. Vestibular neuritis can be differentiated from BPPV by the speed of onset. It develops over minutes rather than seconds.2
In vestibular neuritis there will be a spontaneous unidirectional nystagmus. The critical clinical sign needed to distinguish a central from a peripheral cause of vertigo is called the head impulse test (see online demonstration).1
The head impulse test is positive when there is peripheral labyrinthine loss (as occurs in vestibular neuritis). In patients complaining of severe vertigo but with a normal head impulse test, migraine or stroke must be considered.
Always perform otoscopy to look for vesicles of herpes zoster.
Vertigo in stroke is usually hyperacute in onset (<1s), except when onset occurs in sleep. New-onset headache in vertigo is a red flag since about a third of patients with ischaemic posterior circulation strokes will have headache, typically occipital.
The most common symptom of a cerebellar stroke is vertigo (usually severe), often accompanied by occipital headache. Occasionally, patients with strokes confined to the cerebellar hemisphere (i.e. not involving cerebellar nuclei or brainstem) may complain of isolated vertigo and rarely there maybe little or no nystagmus.
In patients presenting with new-onset migraine, headache and vertigo, distinguishing from cerebellar stroke can be difficult, even for the expert. In both cerebellar stroke, and migraine with vertigo, the head impulse test will be normal.
Emergency neuro-imaging may be indicated if there is any doubt about the diagnosis.
Meniere's disease attacks start with a feeling of fullness in one ear, leading to progressive tinnitus, ipsilateral fluctuating hearing loss and severe vertigo.3
Acute examination will demonstrate unilateral vestibular loss (e.g. unilaterally impaired head impulse test) and unilateral hearing loss. Beware that Meniere's disease is in fact uncommon and over- diagnosed.
Patients with suspected Meniere's disease should be seen in a specialist clinic with adequate audiovestibular testing facilities.
Acute vertigo red flags
One or more of the following additional features in a patient with acute and persisting vertigo should warrant urgent referral:
- new-onset headache
- negative head impulse test
- acute deafness
- any central neurological signs (including gait ataxia)
Section 3 Treatment
The Semont1 or Epley manoeuvre effect an 80 per cent cure with one treatment in expert hands.4
Always ask patients about neck problems before performing positional manoeuvres. The Semont may be more practical to perform in elderly patients with stiff necks.
If you suspect BPPV, a routine out-patient referral to a specialist is usually adequate.
Although there is some evidence to support the use of steroids in acute vestibular neuritis,5 in our opinion further trials are warranted before steroid therapy can be routinely recommended.
If herpetic vesicles are seen on otoscopy or elsewhere, then the patient should be urgently admitted and treated with aciclovir.
There is often an underlying immunodeficiency state (e.g. lymphoma) in herpetic vestibular neuritis. Other cranial nerves (e.g. facial nerve) may be involved.
In uncomplicated vestibular neuritis, bed rest and vestibular sedatives may be advised in the first two or three days. After that the patient should mobilise. Vestibular sedatives should not be used for more than three days. Some patients may be rendered Parkinsonian by their chronic use.
Making the diagnosis is the biggest challenge. GPs who are not expert in performing the head impulse test could consider referral to the emergency department, as there is better access to expert opinion.
A brain scan is not usually required in the diagnostic workup of vestibular neuritis.
A patient with a diagnosis of vestibular neuritis who remains highly symptomatic (i.e. prominent nausea, vomiting and bed-bound) after more than four days, should be referred for an urgent in-patient assessment.
Protracted nausea and vomiting may occasionally be due to a central lesion; and patients who do not mobilise early on following vestibular neuritis are at risk of developing chronic vestibular symptoms.
Early expert intervention may help to avert chronic symptoms.
Antimigraine therapy, both acute and prophylactic, is efficacious in patients with migraine and vertigo as a prominent or only symptom.
In new-onset migraine with vertigo, when there is doubt about the diagnosis (query cerebellar stroke), then referral to the emergency department is indicated.
In contrast, patients with recurrent vertigo (with or without headache) but without interictal signs or symptoms, can be referred as a routine out-patient.
Suspected stroke should be urgently referred to a specialist stroke unit. CT and MRI, as shown above, may confirm a cerebellar stroke. A 'wait and see' approach is untenable if stroke is a differential diagnosis. Stroke treatment is not covered here.
Section 4 Rare, controversial diagnoses
Vertebrobasilar insufficiency provoked by neck movement, as a cause of isolated vertigo, must be extremely rare.6 We have not seen a convincing case. Patients with such symptoms are more likely to have BPPV.
Cervical vertigo, i.e. vertigo due to direct neck injury, is a questionable diagnosis.7
If dizziness can be caused by abnormal sensory signals from the neck, then it should take the form of mild disorientation and not vertigo, in keeping with abnormal perceptions reported with other disorders of the spine.
When vertigo follows a head/neck injury (e.g. whiplash), one must consider BPPV or migraine. In such cases, it is mandatory to perform a Hallpike test. Antimigraine treatment (e.g. propanolol, pizotifen or amitriptyline) should also be considered even in the absence of headache (since headache is not patho-gnomnic in migraine).
Very rarely, patients with neck trauma suffer a vertebral artery dissection, which may cause a brain-stem stroke. Vertebral artery dissection has been reported following trivial neck trauma as well as following chiropractic neck manipulation.8
It is important to define exactly what the patient feels. 'Dizziness' is not enough.
An adequate examination of the acutely vertiginous patient must include a head impulse test and a Hallpike test.1
Seek neurological advice if you are not sure after considering the above.
1.Management of dizziness and vertigo (including 'how-to-do-it' videos) www.imperial.ac.uk/medicine/balance/research
2.Seemungal B M and Bronstein A M. A practical approach to acute vertigo. Pract Neurol 2008;8(4): 211-21.
3. Minor L B, Schessel D A, Carey J P. Meniere's disease. Curr Opin Neurol 2004; 17(1): 9-16.
4. White J, Savvides P, Cherian N, Oas J. Canalith repositioning for benign paroxysmal positional vertigo. Otol Neurotol 2005; 26: 704-10.
5. Strupp M et al. Methylprednisolone, valacyclovir, or the combination for vestibular neuritis. N Engl J Med 2004; 351: 354-61.
6.Sultan M J, Hartshorne T, Naylor A R. Extracranial and transcranial ultrasound assessment in patients with suspected positional 'Vertebrobasilar Ischaemia'. Eur J Vasc Endovasc Surg 2009 Apr 2 (Epub).
7. Brandt T, Bronstein A M. Cervical vertigo. J Neurol Neurosurg Psychiatry 2001; 71: 8-12.
8. Dziewas R, Konrad C, Drager B et al. Cervical artery dissection - clinical features, risk factors, therapy and outcome in 126 patients. J Neurol 2003; 250(10): 1,179-84.
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