HISTORYThe history is of fundamental importance and

in many instances will lead to the correct diagnosis. Careful questioning will allow the physician to separate problems of dizziness from vertigo, which is the first step

Vertigo is an hallucination of motion in which either the patient feels himself spinning or the surroundings spinning.

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HISTORYDizziness, on the other hand, implies

something else. The nearest approximation is usually lightheadedness, unsteadiness, or a feeling of faintness.

Once it has been determined that the patient has vertigo, it is very important to localize the source of the pathophysiologic abnormality by separating peripheral or ear problems from central nervous system disorders.

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Differentiation of central from peripheral VertigoSymptoms Peripheral Central

Hallucination of movement

Definite Less definite

Onset Usually paroxysmal Seldom paroxysmal

Intensity Usually severe Seldom severe

Duration Usually short Longer

Influence of head position

Frequent Seldom

Nystagmus Present Present or absent

Autonomic nervous system

Definite Less intense or absent

Tinnitus Frequently present Seldom present

Deafness Frequently present Seldom present

Disturbances of consciousness

Seldom present More frequently present

Other neurologic signs

Usually absent Frequently absent

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Causes of peripheral vertigoEar: Acute and chronic otitis media

Acute and chronic mastoiditis CholesteatomaLocal traumaForeign body or impacted cerumen

Meniere’s syndromeBenign Positional VertigoVestibular neuronitisOtotoxic drugsOtosclerosisMotion sicknessPsychogenic

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Causes of central VertigoVertebrobasilar insufficiencyStroke (cerebellar)Acoustic neuromaTumors (cerebellar or brain stem)Degenerative disease of CNS (eg multiple

sclerosis)Head traumaPsychogenicEpilepsyMigraine equivalent

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Drugs that may cause vertigo1. Certain Antibiotics:

streptomicingentamicinneomycinkanamycin

2. Diuretics:furosemide

3. Aspirin

4. Quinidine5. Caffeine6. Certain sedatives7. Phenytoin8. Sulfonamide9. Certain toxins:

alcoholtobaccocarbon monoxide

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Causes of dizzinessArterial causes :

Vessel wall : Arteriosclerosis, hypertension External compression

Vessel contents : Abnormalities of cellular elements or plasma

Blood volume disturbancesCardiac causes : Mechanical obstruction

(valvular and other) Pump failure Arrythmias

Metabolic : Hypoglycemia Hyperventilation

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DrugsPsychogenicOcularDental malocclusionSystemic DiseaseMigraine equivalentProprioceptive disorders (peripheral

neuropathy)Vitamin deficiencyAlcoholismDiabetes mellitusPernicious anemia 9

Causes of dizziness

Diagnosis of VertigoThe physical examination should include

measurements of orthostatic vital signs and an otoscopic examination.

The neurologic examination should include the Dix-Hallpike maneuver to differentiate peripheral from central vertigo.

No laboratory testing is absolutely indicated in the work-up of patients with vertigo.

If hearing loss is suspected, complete audiometric testing can help distinguish vestibular pathology from retrocochlear pathology (e.g., acoustic neuroma).

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Diagnosis of VertigoBrain imaging is warranted if a tumor or

stroke is suspected.MRI with contrast medium is recommended

when a patient presents with acute vertigo and sensorineural hearing loss.

Magnetic resonance angiography can be used to evaluate the vertebrobasilar circulation

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DIX-HALLPIKE MANEUVERDix-Hallpike maneuver is used to diagnose

benign paroxysmal positional vertigoThis test consists of a series of two

maneuvers:With the patient sitting on the examination

table, facing forward, eyes open, the physician turns the patient’s head 45 degrees to the right

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DIX-HALLPIKE MANEUVER• The physician supports

the patient’s head as the patient lies back quickly from a sitting to supine position

• ending with the head hanging 20 degrees off the end of the examination table

• The patient remains in this position for 30 seconds

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DIX-HALLPIKE MANEUVER• Then the patient returns

to the upright position and is observed for 30 seconds

• Next, the maneuver is repeated with the patient’s head turned to the left

• A positive test is indicated if any of these maneuvers provide vertigo with or without nystagmus

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DIX-HALLPIKE MANEUVER

http://www.dizziness-and-balance.com/sitedvd.htm

Management of an acute vertigo attackAn acute and severe episode of vertigo,

regardless of the underlying cause, will usually settle by itself within 24–48 hours due to the effect of brainstem compensation.

During the acute phase, supportive measures, bed rest, antiemetics and vestibular blocking agents can be used to provide symptomatic relief.

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General Treatment Principles

MEDICATIONSMedications are most useful for treating acute vertigo

that lasts a few hours to several days.They have limited benefit in patients with benign

paroxysmal positional vertigo, because the vertiginous episodes usually last less than one minute.

Vertigo lasting more than a few days is suggestive of permanent vestibular injury (e.g., stroke), and medications should be stopped to allow the brain to adapt to new vestibular input.

A wide variety of medications are used to treat vertigo and the frequently concurrent nausea and emesis.

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These medications exhibit various combinations of acetylcholine, dopamine, and histamine receptor antagonism.

Anticholinergics and antihistamines are recommended for the treatment of nausea associated with vertigo or motion sickness.

Gamma-aminobutyric acid (GABA) is an inhibitory neurotransmitter in the vestibular system.

Benzodiazepines enhance the action of GABA in the central nervous system (CNS) and are effective in relieving vertigo and anxiety

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19*Betahistine also selectively increase the blood flow to the inner ear

Vestibular blocking agent

Dosage

Antihistamines Promethazine 12,5-25,0 mg orally, IM or rectally every 4-12 hours

Betahistine*( BETASERC )

4-16 mg 8 hourly per day

Benzodiazepines Diazepam 2-10 mg orally or IV every 4-8 hours

Lorazepam 0,5-2,0 mg orally, IM or IV every 4-8 hours

Antiemetics Prochlorperazine 5-10 mg orally or IM every 6-8 hours or 25 mg every 12 hours

Metoclopramide 10-20 mg orally every 6 hours or 10-20 mg by slow IV every 6-8 hours

VESTIBULAR REHABILITATION EXERCISESVestibular rehabilitation exercises commonly are

included in the treatment of vertigo.These exercises train the brain to use alternative

visual and proprioceptive cues to maintain balance and gait.

It is necessary for a patient to reexperience vertigo so that the brain can adapt to a new baseline of vestibular function.

After acute stabilization of the patient with vertigo, use of vestibular suppressant medications should be minimized to facilitate the brain’s adaptation to new vestibular input

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Cawthorne – Cooksey ExerciseIn bed or sitting1. Eye movements - at first slow, then

quick- up and down

- from side to side

- focusing on finger moving from 3 feet to 1 foot away from face

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Cawthorne – Cooksey Exercise2. Head movements at first slow, then

quick, later with eyes closed- bending forward and

backward - turning from side to

side

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Cawthorne – Cooksey ExerciseSitting

- Eye movements and head movements as above- Shoulder shrugging and circling

- Bending forward and picking up objects from the ground

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Cawthorne – Cooksey ExerciseStanding

- Eye, head and shoulder movements as before

- Changing from sitting to standing position with eyes open and shut

- Throwing a small ball from hand to hand (above eye level)

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Cawthorne – Cooksey Exercise- Throwing a ball from

hand to hand under knee

- Changing from sitting to standing and turning around in between

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Cawthorne – Cooksey ExerciseMoving about (in class)

- Throwing and catching the ball while walking

- Walk arround room with eyesopen and then closed

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- Walk up and down slope with eyes open and then closed

- Walk up and down steps with eyes open and then closed

- Playing any game involving stooping, stretching, and aiming with the ball, such as bowling or basketball

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Cawthorne – Cooksey Exercise

Treatment of Specific DisordersBENIGN PAROXYSMAL POSITIONAL VERTIGOBenign paroxysmal positional vertigo (BPPV) is the

most common underlying cause of vertigo.Benign paroxysmal positional vertigo is caused by

calcium debris in the semicircular canals (canalithiasis), usually the posterior canal.

A canalith is made up of small crystals of calcium carbonate that have detached from the utricle in the vestibule of the inner ear.

Movement of the canalith activates vestibular hair cells to create an overall asymmetrical vestibular input.

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Patients usually experience a brief but intense vertigo when they turn in bed at night or change their head position.

The most important clinical test to perform is the Dix-Hallpike maneuvre.

Medications generally are not recommended for the treatment of this condition.

The vertigo improves with head rotation maneuvers that displace free-moving calcium deposits back to the vestibule.

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Maneuvers include the canalith repositioning procedure or Epley maneuver and the modified Epley maneuver.

The modified Epley maneuver can be performed at home.

Contraindications to canalith repositioning procedures include severe carotid stenosis, unstable heart disease, and severe neck disease, such as cervical spondylosis with myelopathy or advanced rheumatoid arthritis

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EPLEY MANEUVER

The physician supports the patient’s head as the patient lies back quickly from a sitting to supine position

ending with the head hanging 20 degrees off the end of the examination table

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The patient sits on the examination table, with eyes open and head turned 45 degrees to the right

EPLEY MANEUVERThe physician turns

the patient’s head 90 degrees to the left side.

The patient remains in this position for 30 seconds

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EPLEY MANEUVERThe physician turns

the patient’s head an additional 90 degrees to the left while the patient rotates his or her body 90 degrees in the same direction.

The patient remains in this position for 30 seconds

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EPLEY MANEUVERThe patient sits up

on the left side of the examination table

The procedure may be repeated on either side until the patient experiences relief of symptoms.

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EPLEY MANEUVER

VESTIBULAR NEURONITIS AND LABYRINTHITISAcute inflammation of the vestibular

nerve is a common cause of acute, prolonged vertigo. Associated hearing loss occurs if the labyrinth is involved.

The vertigo usually lasts a few days and resolves within several weeks.

Many cases of vestibular neuronitis or labyrinthitis are attributed to self-limited viral infections.

Treatment focuses on symptom relief using vestibular suppressant medications, followed by vestibular exercises.

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MÉNIÈRE’S DISEASEMénière’s disease (or endolymphatic

hydrops) presents with vertigo, tinnitus (low tone, roaring, or blowing quality), fluctuating low-frequency sensorineural hearing loss, and a sense of fullness in the ear.

In this disorder, impaired endolymphatic filtration and excretion in the inner ear leads to distention of the endolymphatic compartment.

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MÉNIÈRE’S DISEASETreatment lowers endolymphatic pressure.

Although a low-salt diet (less than 1 to 2 g of salt per day) and diuretics (most commonly the combination of hydrochlorothiazide and triamterene) often reduce the vertigo, these measures are less effective in treating hearing loss and tinnitus

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VASCULAR ISCHEMIAThe sudden onset of vertigo in a patient with

additional neurologic symptoms (e.g., diplopia, dysarthria, dysphagia, ataxia, weakness) suggests the presence of vascular ischemia.

Treatment of TIA and stroke include preventing future events

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MIGRAINE HEADACHESEpidemiologic evidence shows a strong

association between vertigo and migraine.Diagnostic accuracy is important because

vertiginous migraine may respond better to migraine treatments than to other interventions.

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MIGRAINE HEADACHESTreatments included dietary changes (i.e.,

reduction or elimination of aspartame, chocolate, caffeine, or alcohol), lifestyle changes (i.e., exercise, stress reduction, improvements in sleep patterns), vestibular rehabilitation exercises, and medications (e.g., benzodiazepines, tricyclic antidepressants, beta blockers, selective serotonin reuptake inhibitors, calcium channel blockers, antiemetics).

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CONCLUSIONManagement of vertigo can be a daunting task due to a large number of potential underlying conditions. Treatment for vertigo is still mainly symptomatic. General practitioners play a vital role in providing holistic management to minimise vertigo associated disability and improve the patient's quality of life.

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THANK YOU

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