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Central Nervous System Conditions: Vertigo and Dizziness

Yvonne M. Shevchuk, BSP, PharmD, FCSHP

Date Prepared: May 2010

Pathophysiology

Dizziness refers to a variety of sensations such as lightheadedness, fainting, spinning and giddiness.1 Vertigo isdefined as a sensation of motion where there is none or an exaggerated sense of motion in response to a given

bodily movement.2 It is the cardinal symptom of vestibular disease as a result of lesions or disturbances in theinner ear, eighth cranial nerve or vestibular nuclei and their pathways in the brain stem and cerebellum. Vertigo isusually accompanied by varying degrees of nausea and vomiting as well as pallor and perspiration. It may beacute, chronic or recurrent. Specific conditions that produce vertigo are listed in Table 1.

Dizziness has a number of causes unrelated to ear conditions including cardiovascular conditions (e.g.,arrhythmias, hypertension), metabolic or endocrine conditions (e.g., anemia, diabetes), psychiatric conditions and

neurological conditions (e.g., migraine, head injury).3

Table 1: Specific Conditions That Produce Vertigo

Type Description Treatmenta

Benignparoxysmalpositioningvertigo(BPPV)

Most common type of vertigo(20% of all cases)4

Probable causes, such as viralneuritis (see below), surgery,infection, vasculitis and trauma,identified in approximately 50%

of cases5

Presence of debris or smallcrystals of calcium carbonate(canaliths) in semicircular

canals4

Recurrent bouts of vertigo(brief) resulting from changes in

head position5

Hearing loss and tinnitus notusually presentSymptoms may disappear in afew weeks but may recur

Physical manipulation of the head (e.g., Epley manoeuvre)6 much

more useful than drug therapy.4 Epley manoeuvre is a specific

sequence of head position changes performed by a physician thatmoves particles into the posterior semicircular canal toward theutricle6

Nausea treated with antiemetics 4

Vestibular rehabilitation (physical therapy program to improvebalance, eye-hand coordination and habituate the patient to

feelings of dizziness)5

Meniere’sdisease

2nd most common cause ofvertigo of otologic origin4

Associated with distention of theendolymphatic compartment ofthe inner earFluctuating hearing, roaringtinnitus, aural fullness and

vertigo5

Vertigo has acute onset andpersists from 30 min to severalhours

Vestibular suppressants with or without antiemetics to treatacute attacks4

ProphylaxisDietary salt restriction (1–2 g/day), avoidance of caffeine and

smoking4

Diuretics, e.g., hydrochlorothiazide-triamterene (avoid loop

diuretics) often recommended but little evidence for benefit7

Betahistine is commonly used even though benefit is not

well established8

Avoid vestibular suppressants for prophylaxis as they

may impair vestibular compensation4

Vestibularneuritis

Self-limiting, preceded by anonspecific viral infection4 , 5

Due to viral infection of thevestibular portion of the eighth

cranial nerve4

Sudden onset vertigo, nausea,

ataxia and nystagmus4 , 5

Generally no hearingimpairment; if hearing

Reassurance and explanation; prognosis is excellentAvoid movement as this exacerbates symptoms and usevestibular suppressants and antiemetics for 2–3 days after

which symptoms have usually significantly decreased4

Use as few medications as possible and encourage as much

activity as tolerated so compensation is not delayed4 , 5

Methylprednisolone may have a role in vestibular recovery9

BPPV may occur in up to 15% of patients with vestibular neuritis



impairment present, is referred

to as labyrinthitis4

Symptoms constant for 2–3

days4

Centralvertigo

Less than 5% of cases4

Often caused by vasculardisorders, e.g., stroke, transient

ischemic attack, migraine4

Treat underlying cause4

a. See Table 3 for description of nonprescription pharmacologic agents.

Drug-induced causes of dizziness are listed in Table 2. Ototoxic drugs may also produce vertigo (see Ear

Conditions: Assessment of Patients with Hearing Loss, Ear Pain and Ear Drainage, Table 2).

Table 2: Medications That May Cause Dizziness

Class of Medication Probable Mechanism Example

Alpha1-adrenergic antagonists Orthostatic hypotension Prazosin

Alcohol Hypotension, osmotic effects Wine, cough syrups

Aminoglycosides Ototoxicity Gentamicin

Antiepileptic drugs Orthostatic hypotension Carbamazepine

Antidepressants Orthostatic hypotension Desipramine

Anti-parkinsonian medication Orthostatic hypotension Levodopa

Antipsychotics Orthostatic hypotension Olanzapine

Beta-blockers Hypotension or bradycardia Atenolol

Calcium channel blockers Hypotension, vasodilation Verapamil

Class la antiarrhythmics Torsades de pointes Procainamide

Digitalis glycosides Hypotension Digoxin

Diuretics Volume contraction, vasodilation Hydrochlorothiazide

Narcotics Central nervous system depression Morphine, propoxyphene

Sulfonylureas Hypoglycemia Glyburide, tolbutamide

Vasodilators Hypotension, vasodilation Hydralazine

Reproduced with permission from Sloane PD et al. Dizziness: state of the science. Ann Intern Med 2001;134:823-32.

Goals of Therapy

Reduce or eliminate symptoms of vertigo4

Reduce or eliminate nausea and anxiety4

Avoid compromising the process of vestibular compensation (allowing the brain to find a new sensory

equilibrium despite the vestibular lesion)4

Patient Assessment

Always seek drug-induced causes of vertigo and dizziness. All patients with vertigo should be assessed by aphysician. If the vertigo is accompanied by numbness, tingling or weakness in any part of the body, visualdisturbances, confusion or difficulty speaking, this is an emergency. Call 911 as the patient may be experiencing atransient ischemic attack or stroke.

Nonpharmacologic Therapy



Nonpharmacologic therapy depends on the cause of the vertigo; see Table 1.

Pharmacologic Therapy

Drug therapy for vertigo is symptomatic; in the majority of cases the mechanism of the vertigo is unknown andspecific therapy can therefore not be determined. Unless a specific cause of vertigo is known (e.g., Meniere’sdisease), the choice of pharmacologic agent for treatment depends on the adverse effect profile of the drug,presence of contraindications and cost. Most drugs used in vertigo down-regulate vestibular excitability (vestibular

suppressants).4 Table 3 describes nonprescription agents used to treat vertigo. Prescription drugs used to treat

vertigo include benzodiazepines,4 betahistine 10 and flunarizine.4 , 8 , 11 Very few drugs (nonprescription orprescription) have been properly evaluated for the treatment of vertigo.

Table 3: Nonprescription Drugs for Vertigo4

For product selection, consult the tables in Products for Minor Ailments. Gastrointestinal Products:

Antiemetics.

Class Drug Dose Adverse Effects Comments

Vestibularsuppressant/antiemetics

dimenhydrinate

25–50 mg Q6H poor 100 mg Q8H pr

Drowsiness, anticholinergiceffects (dry mouth, mydriasis,blurred vision, constipation,urinary retention, confusion).

Avoid combining withCNS depressants.Contraindicated in angleclosure glaucoma,prostatic hypertrophyand urinary retention.

Vestibularsuppressant/antiemetics

scopolamine Transdermal patch(1.5 mg delivers 1mg over 3 days) 1patch Q72H

Drowsiness, anticholinergiceffects (dry mouth, mydriasis,blurred vision, constipation,urinary retention, confusion)..Local reactions/allergies.


Antiemetics promethazine 25 mg Q6–8H pofor nausea

Drowsiness, anticholinergiceffects (dry mouth, mydriasis,blurred vision, constipation,urinary retention, confusion)..Extrapyramidal reactions.


Although these drugs may reduce vertigo, they also reduce vestibular function in the normal ear, which is adisadvantage. Vestibular suppressants reduce or slow down vestibular compensation and prevent the CNS from

receiving the necessary feedback to facilitate compensation.4 For this reason, anticholinergics, antihistamines andbenzodiazepines are not intended for long-term use. In most cases the duration of treatment would be a week orless.

Monitoring of Therapy

Vertigo is often self-limiting. Evaluate the need for continued use of medication daily, at least initially. Determinethe severity, duration and frequency of the vertigo. Monitor the patient for relief of vertigo and associatedsymptoms such as nausea, vomiting and anxiety. If no improvement of vertigo is noted, discontinue drug therapy.Monitor patients for adverse effects such as drowsiness and anticholinergic effects.

Advice for the Patient

Counsel patients who receive drug therapy regarding:

Expected duration of treatmentManagement of side effects (Table 3)Instructions not to combine drug therapy with alcohol.



Suggested Readings

Hain TC, Uddin M. Pharmacologic treatment of vertigo. CNS Drugs 2003;17:85-100.

Sloane PD, Coeytaux RR, Beck RS et al. Dizziness: state of the science. Ann Intern Med 2001;134:823-32.

References

1. Daroff RB. Dizziness and vertigo. In: Fauci AS et al., editors. Harrison’s principles of internal medicine. 17th

ed. New York: McGraw-Hill; 2008. p. 139-43.

2. Lustig LR, Schindler J. Ear, nose and throat disorders. In: McPhee P, McPhee SJ, Papadakis MA, editors.

Current medical diagnosis and treatment 2009. 48th ed. New York: Lange Medical Books/McGraw Hill; 2009.

p.173-208.

3. Kerber KA. Vertigo and dizziness in the emergency department. Emerg Med Clin North Am 2009;27:39-50.

4. Hain TC, Uddin M. Pharmacologic treatment of vertigo. CNS Drugs 2003;17:85-100.

5. Hanley K, O’Dowd, Considine N. A systematic review of vertigo in primary care. Br J Gen Pract 2001;51:666-

71.

6. Froehling DA, Bowen JM, Mohr DN et al. The canalith repositioning procedure for the treatment of benign

paroxysmal positional vertigo: a randomized controlled trial. Mayo Clin Proc 2000;75:695-700.

7. Burgess A, Kundu S. Diuretics for Meniere’s disease or syndrome. Cochrane Database Syst Rev

2006;3:CD003599.

8. James AL, Burton MJ. Betahistine for Meniere’s disease or syndrome. Cochrane Database Syst Rev

2001;1:CD001873.

9. Strupp M, Zingler VC, Arbusow V et al. Methyprednisolone, valacyclovir, or the combination for vestibular

neuritis. N Engl J Med 2004;351:354-61.

10. Della Pepa C, Guidetti M, Eandi M. Betahistine in the treatment of vertiginous syndromes: a meta-analysis.

Acta Otorhinolaryngol Ital 2006;26:208-15.

11. Haid T. Evaluation of flunarizine in patients with Meniere’s disease. Subjective and vestibular findings. Acta

Otolaryngol Suppl 1988;460:149-53.

Vertigo — What You Need to Know

What is vertigo?

Vertigo is a kind of dizziness where it feels like you or your environment is moving or spinning. It often makespeople feel sick to their stomach.

What causes vertigo?

Vertigo can be caused by many things, including viral infections and inner ear problems. Sometimes it goes awayon its own. Other times the body learns to ignore the feeling. Anyone with vertigo should see a doctor to findout what is causing it.

What is the treatment for vertigo?

Medication can be used to treat vertigo and the upset stomach it causes. However, medications will not fix theproblem. They may even keep your body from learning to ignore the vertigo.

If you suffer from attacks of vertigo, avoid activities that may be dangerous (such as climbing ladders, driving andoperating machinery).

Important information about medications used to treat vertigo:

Medications used to treat vertigo may cause:drowsiness or blurred vision—use caution driving and operating dangerous machinerydry mouth—sugarless candy or gum may help relieve drynessconstipation—drink plenty of water and eat high-fibre foods

Don’t combine these medications with alcohol or other drugs that might make you drowsy or less alert.

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