vertigo 2010
TRANSCRIPT
VERTIGOVERTIGO
AYESHA SHAIKHPGY2
EMORY FAMILY MEDICINE 09.17.2008
AYESHA SHAIKHPGY2
EMORY FAMILY MEDICINE 09.17.2008
CASECASE
31,female doctor, otherwise healthy, post partum week 5.
First episode, sudden feeling of room spinning, while entering patient data in computer, during Family Medicine Clinic… One fine day last year same time!
31,female doctor, otherwise healthy, post partum week 5.
First episode, sudden feeling of room spinning, while entering patient data in computer, during Family Medicine Clinic… One fine day last year same time!
DIZZINESSDIZZINESS
• Vertigo• Lightheadedness• Pre syncope• Dys-equilibrium
• Vertigo• Lightheadedness• Pre syncope• Dys-equilibrium
VERTIGOVERTIGO
FALSE SENSE OF MOTION, usually rotational.
2 TYPES1- CENTERAL VESTIBULAR CAUSES(Brain stem or cerebellum)2- PERIPHERAL VESTIBULAR CAUSES( Labyrinth or vestibular nerve)
FALSE SENSE OF MOTION, usually rotational.
2 TYPES1- CENTERAL VESTIBULAR CAUSES(Brain stem or cerebellum)2- PERIPHERAL VESTIBULAR CAUSES( Labyrinth or vestibular nerve)
CAUSES OF VERTIGOCAUSES OF VERTIGO
CENTRALCerebellopontine
angle tumorCerebrovascular
diseaseMigraineMultiple sclerosis
CENTRALCerebellopontine
angle tumorCerebrovascular
diseaseMigraineMultiple sclerosis
PERIPHERAL Acute labrynthitis Vestibular neuritis BPPV Cholestotoma Menier’s disease Ostosclerosis Perilymphatic fistula
PERIPHERAL Acute labrynthitis Vestibular neuritis BPPV Cholestotoma Menier’s disease Ostosclerosis Perilymphatic fistula
Causes..Causes..
DrugsAlcoholAminoglycosidesAnticonvulsants AntidepressantsAntihypertensivesBarbituratesCocaine( Slowly progressive Unilateral/Bilateral)
DrugsAlcoholAminoglycosidesAnticonvulsants AntidepressantsAntihypertensivesBarbituratesCocaine( Slowly progressive Unilateral/Bilateral)
HistoryHistory
TimingsDurationProvoking, aggreviating factorsAssociated symptomsRisk factors for Cardiovascular disease
Q: When you have dizzy spells , do you feel lightheaded or do you see the world spin around you?
Q: Duration of Vertigo and associated symptoms? ( differentiate peripheral vs central causes)
TimingsDurationProvoking, aggreviating factorsAssociated symptomsRisk factors for Cardiovascular disease
Q: When you have dizzy spells , do you feel lightheaded or do you see the world spin around you?
Q: Duration of Vertigo and associated symptoms? ( differentiate peripheral vs central causes)
Typical Duration of Symptoms for Different Causes of Vertigo
Duration of episode Suggested diagnosis
A few seconds Peripheral cause: unilateral loss of vestibular function; late stages of acute vestibular neuronitis; late stages of Ménière's disease Several secondsto a few minutes Benign paroxysmal positional vertigo; perilymphatic fistula
Several minutes to one hour Posterior transient ischemic attack; perilymphatic fistula
Hours Ménière's disease; perilymphatic fistula from trauma or surgery; migraine; acoustic neuroma
Days Early acute vestibular neuronitis*; stroke; migraine; multiple sclerosis
Weeks Psychogenic (constant vertigo lasting weeks without improvement)
*-Vertigo with early acute vestibular neuritis can last as briefly as two days or as long as one week or more.
Information from references 3, 6, and 12.
Provoking Factors for Different Causes of Vertigo
Provoking factor Suggested diagnosis
•Changes in head position Acute labyrinthitis; benign positional paroxysmal vertigo; cerebellopontine angle tumor; multiple sclerosis; perilymphatic fistula
•Spontaneous episodes Acute vestibular neuronitis; cerebrovascular disease (stroke or transient ischemic attack); (i.e., no consistent Ménière's disease; migraine; multiple sclerosis•provoking factors)
•Recent upper respiratory viral illness Acute vestibular neuronitis
•Stress Psychiatric or psychological causes; migraine
•Immunosuppression (e.g., immunosuppressive Herpes zoster oticus medications, advanced age, stress)
•Changes in ear pressure, Perilymphatic fistula head trauma, excessive straining, loud noises
•Information from references 1, 3, 5, 12, and 13.
Associated Symptoms for Different Causes of Vertigo
Symptom Suggested diagnosis
Aural fullness Acoustic neuroma; Ménière's disease
Ear or mastoid pain Acoustic neuroma; acute middle ear disease (e.g., otitis media, herpes zoster oticus)
Facial weakness Acoustic neuroma; herpes zoster oticus
Focal neurologic Cerebellopontine angle tumor; cerebrovascular disease; findings) multiple sclerosis (especially findings not explained by single neurologic lesion
Headache Acoustic neuroma; migraine
Hearing loss Ménière's disease; perilymphatic fistula; acoustic neuroma; cholesteatoma; otosclerosis; transient ischemic attack or stroke involving anterior inferior cerebellar artery,herpes zoster oticus
Imbalance Acute vestibular neuronitis (usually moderate); cerebellopontine angle tumor (usually severe)
Nystagmus Peripheral or central vertigo
Phonophobia, photophobia Migraine
Tinnitus Acute labyrinthitis; acoustic neuroma; Ménière's disease
Information from references 1, 6, and 12 through 14.
Table 5
Causes of Vertigo Associated with Hearing Loss Diagnosis Characteristics of hearing loss
Acoustic neuroma Progressive, unilateral, sensorineural
Cholesteatoma Progressive, unilateral, conductive
Herpes zoster oticus (i.e., Ramsay Hun syndrome) Subacute to acute onset, unilateral
Ménière's diseases Sensorineural, initially fluctuating, initially affecting lower frequencies; later in course: progressive, affecting higher frequencies
Otosclerosis Progressive, conductive
Perilymphatic fistula Progressive, unilateral
Transient ischemic attack orstroke involving anterior inferior cerebellarartery or internal auditory artery Sudden onset, unilateral
Information from references 9, 12, and 13.
Distinguishing Characteristics of Peripheral vs. Central Causes of Vertigo
Feature Peripheral vertigo Central vertigo
Nystagmus Combined horizontal and torsional; Purely vertical, horizontal, or torsional inhibited by fixation of eyes onto object; ; not inhibited by fixation of eyes onto object; fades after a few days; does not change may last weeks to months direction with gaze to either side ; may change direction with gaze
Imbalance Mild to moderate; able to walk Severe; unable to stand still or walk
Nausea May be severe Varies, vomiting
Hearing loss, tinnitus Common Rare
Nonauditory Rare Commonneurologic symptoms
Latency followingprovocative diagnostic Longer (up to 20 seconds) Shorter (up to 5 seconds)maneuver)
Information from references 14 and 15.
Physical ExamPhysical Exam
Special attention to head and neckCardiovascular and neurologic
symptomsProvocative diagnostic tests
Special attention to head and neckCardiovascular and neurologic
symptomsProvocative diagnostic tests
Physical ExamPhysical Exam
Vertical nystagmus is 80% sensitive for central lesions.
Horizontal nystagmus for peripheral lesions.
Rhomberg sign : sensitivity 19 % only for peripheral causes.
Dix-Hallpike maneuver PPV 83%, NPV 52 %.
Vertical nystagmus is 80% sensitive for central lesions.
Horizontal nystagmus for peripheral lesions.
Rhomberg sign : sensitivity 19 % only for peripheral causes.
Dix-Hallpike maneuver PPV 83%, NPV 52 %.
Clues to Distinguish Between Peripheral and Central Vertigo
Clues Peripheral vertigo Central vertigo
Findings on Latency of symptoms None Dix-Hallpike and nystagmus 2 to 40 secondsmaneuver
Severity of vertigo Severe Mild
Duration of nystagmus Usually< 1 minute Usually>1 minute
Fatigability* Yes No Habituation† Yes No
Other findings
Postural instability Able to walk; Falls while walking; unidirectional instability severe instabilityHearing loss or tinnitus Can be present Usually absent
Other neurologic Symptoms Absent Usually present
*-Response remits spontaneously as position is maintained.
†-Attenuation of response as position repeatedly is assumed.
Information from references 3 and 4.
Diagnosis Diagnosis
History Physical Exam: Orthostatic vital signs, and
Otoscopic examination, Neurologic Exam: Dix-Hallpike Maneuver
( central vs Peripheral) Complete Audiometric Testing for suspected
Menier’s disease
No LAB testing! Brain imaging : MRI with contrast for acute vertigo and
Sensorineural hearing loss, MRA for vertebrobasilar circulation
History Physical Exam: Orthostatic vital signs, and
Otoscopic examination, Neurologic Exam: Dix-Hallpike Maneuver
( central vs Peripheral) Complete Audiometric Testing for suspected
Menier’s disease
No LAB testing! Brain imaging : MRI with contrast for acute vertigo and
Sensorineural hearing loss, MRA for vertebrobasilar circulation
Disorder Duration Auditory symptoms
Prevalence Peripheral or central vertigo
Benign paroxysmal positional vertigo
Seconds No Common Peripheral
Perilymphatic fistula (head trauma, barotrauma)
Seconds Yes Uncommon Peripheral
Vascular Ischemia,TIA Seconds to hours Usualy not Uncommon Central or peripheral
Meniere’s disease Hours yes common peripheral
Syphillis Hours yes Uncommon central
Vertiginous migraine Hours No Common Central
Labyrinthitis Days Yes common peripheral
Vascular Ischemia: Stroke Days Usually not Uncommon Central or peripheral
Vestibular neuronitis Days No Common Peripheral
Anxiety disorder Variable Usually not Common Unspecified
Acoustic neuroma months yes Uncommon Peripheral
Multiple sclerosis Months no uncommon central
Vestibular ototoxicity months yes uncommon peripheral
General Treatment Principles
General Treatment Principles
Medication for Acute Vertigo that lasts for few hours to several days
Medications have various combinations of acetylecholine, dopamineand histamine receptor antagonism.
Benzodiazepines enhance GABA action ( GABA is inhibitory neurotransmitter in vestibular system)
Medication for Acute Vertigo that lasts for few hours to several days
Medications have various combinations of acetylecholine, dopamineand histamine receptor antagonism.
Benzodiazepines enhance GABA action ( GABA is inhibitory neurotransmitter in vestibular system)
Strength of Recommendation
Key clinical recommendation
•The canalith repositioning procedure (Epley maneuver) is recommended in patients with benign paroxysmal positional vertigo. A
•The modified Epley maneuver also is effective in patients with benign paroxysmal positional vertigo.B
•Vestibular suppressant medication is recommended for symptom relief in patients with acute vestibular neuronitis. C
•Vestibular exercises are recommended for more rapid and complete vestibular compensation in patients with acute vestibular neuronitis. B
•Treatment with a low-salt diet and diuretics is recommended for patients with Ménière's disease and vertigo.B
•Effective treatments for vertiginous migraine include migraine prophylaxis (e.g., tricyclic antidepressants, beta blockers, calcium channel blockers), migraine-abortive medications (e.g., sumatriptan [Imitrex]), and vestibular rehabilitation exercises B
•Selective serotonin reuptake inhibitors can relieve vertigo in patients with anxiety disorders. Because of side effects, slow titration is recommended.B
A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, opinion, or case series. See page 1046 for more information.
MedicationsMedications Meclizine* (Antivert) 12.5 to 50 mg orally every 4 to 8 hour Dimenhydrinate* (Dramamine) 25 to 100 mg orally, IM, or IV
every 4 to 8 hours Diazepam (Valium) 2 to 10 mg orally or IV every 4 to 8 hours Lorazepam (Ativan) 0.5 to 2 mg orally, IM, or IV every 4 to 8
hours Metoclopramide (Reglan) 5 to 10 mg orally every 6 hours 5 to 10 mg by slow IV every 6 hours Prochlorperazine (Compazine) 5 to 10 mg orally or IM every 6
to 8 hours 25 mg rectally every 12 hours 5 to 10 mg by slow IV over 2
minutes Promethazine (Phenergan) 12.5 to 25 mg orally, IM, or rectally
every 4 to 12 hours
Meclizine* (Antivert) 12.5 to 50 mg orally every 4 to 8 hour Dimenhydrinate* (Dramamine) 25 to 100 mg orally, IM, or IV
every 4 to 8 hours Diazepam (Valium) 2 to 10 mg orally or IV every 4 to 8 hours Lorazepam (Ativan) 0.5 to 2 mg orally, IM, or IV every 4 to 8
hours Metoclopramide (Reglan) 5 to 10 mg orally every 6 hours 5 to 10 mg by slow IV every 6 hours Prochlorperazine (Compazine) 5 to 10 mg orally or IM every 6
to 8 hours 25 mg rectally every 12 hours 5 to 10 mg by slow IV over 2
minutes Promethazine (Phenergan) 12.5 to 25 mg orally, IM, or rectally
every 4 to 12 hours
Vestibular Rehabilitation Exercises
Vestibular Rehabilitation Exercises
These exercises train the brain to use alternative visual and proprioceptive clues to maintain balance and gait.
Improve postural control during the first month after acute unilateral vestibular lesions resulting from vestibular neuronitis.
These exercises train the brain to use alternative visual and proprioceptive clues to maintain balance and gait.
Improve postural control during the first month after acute unilateral vestibular lesions resulting from vestibular neuronitis.
Treatment of Specific DisordersTreatment of Specific Disorders 1- BPPV (Usually posterior canal Calcium Debris)
MEDS..? Head Rotation Maneuvers Eply ManeuverContraindication: Severe carotid stenosis, unstable
heart disease, severe neck diseaseSuccess rate: 80 % after one treatment, 100%
with repeated treatments.Recurrence rates: 15% /year, 20% @ 20 months,
and 37% @ 60 months.
1- BPPV (Usually posterior canal Calcium Debris)
MEDS..? Head Rotation Maneuvers Eply ManeuverContraindication: Severe carotid stenosis, unstable
heart disease, severe neck diseaseSuccess rate: 80 % after one treatment, 100%
with repeated treatments.Recurrence rates: 15% /year, 20% @ 20 months,
and 37% @ 60 months.
Treatment of specific DisordersTreatment of specific Disorders
2- Vestibular Neuronitis ( Acute Prolonged Vertigo) Symptom relief using vestibular suppressant
medications, followed by vestibular exercises.
Vestibular compensations occurs more rapidly and more completely if the patient begins twice-daily vestibular rehabilitation exercises soon after symptom control with medications.
2- Vestibular Neuronitis ( Acute Prolonged Vertigo) Symptom relief using vestibular suppressant
medications, followed by vestibular exercises.
Vestibular compensations occurs more rapidly and more completely if the patient begins twice-daily vestibular rehabilitation exercises soon after symptom control with medications.
Treatment of specific disordersTreatment of specific disorders
3-Menier’s Disease (Distension of Endolymphatic compartment
due to impaired endolymphatic filtration and
excretion)
Low salt diet ( < 1-2 gm/day) Diuretics ( combo HCTZ and Triamterene) Surgery in rare cases - ablation of vestibular
hair cells)
3-Menier’s Disease (Distension of Endolymphatic compartment
due to impaired endolymphatic filtration and
excretion)
Low salt diet ( < 1-2 gm/day) Diuretics ( combo HCTZ and Triamterene) Surgery in rare cases - ablation of vestibular
hair cells)
4- Vascular Ischemia4- Vascular Ischemia (Sudden onset of vertigo with additional symptoms eg
diplopia, ataxia, dysphagia, dysarthria) TIA /Stroke: BP control, Cholesterol Lowering ,
smoking cessation, inhibition of platelet function, anticoagulation
Vestibualr suppressant medications plus minimal head maneuver on first day, then initiate rehabilitation
Vestibular stents for symptomatic critical vertebral artery stenosis.
(Sudden onset of vertigo with additional symptoms eg
diplopia, ataxia, dysphagia, dysarthria) TIA /Stroke: BP control, Cholesterol Lowering ,
smoking cessation, inhibition of platelet function, anticoagulation
Vestibualr suppressant medications plus minimal head maneuver on first day, then initiate rehabilitation
Vestibular stents for symptomatic critical vertebral artery stenosis.
6-Migraine Headaches6-Migraine Headaches
Treat Migraine!
Reduce or eliminate Aspartame, chocolate, caffeine and alcohol, Lifestyle changes, Vestibular rehabilitation exercises.
Meds: BDZ, TCA, BB, SSRI, CCB, Antiemetics.
Treat Migraine!
Reduce or eliminate Aspartame, chocolate, caffeine and alcohol, Lifestyle changes, Vestibular rehabilitation exercises.
Meds: BDZ, TCA, BB, SSRI, CCB, Antiemetics.
7- Psychiatric Disorders7- Psychiatric Disorders
( Anxiety , Panic disorders more common than depression; Hyperventilation is the cause.)
Vesibular supressants and Benzodiazepines- transient to inadequate relief.
SSRI show better relief.
Cognitive behaviour therapy may be helpful.
( Anxiety , Panic disorders more common than depression; Hyperventilation is the cause.)
Vesibular supressants and Benzodiazepines- transient to inadequate relief.
SSRI show better relief.
Cognitive behaviour therapy may be helpful.
Physiologic VertigoPhysiologic Vertigo
Motion sickness: incongruence in the sensory input from the vestibular, visual, and somatosensory systems.Visual system does not sense the movement.
Bring systems back in congruence! Eg watch horizon when on a boat.also scopolamine patch behind ear 4 hours before boating.
Motion sickness: incongruence in the sensory input from the vestibular, visual, and somatosensory systems.Visual system does not sense the movement.
Bring systems back in congruence! Eg watch horizon when on a boat.also scopolamine patch behind ear 4 hours before boating.
Disorder Duration Auditory symptoms
Prevalence Peripheral or central vertigo
Benign paroxysmal positional vertigo
Seconds No Common Peripheral
Perilymphatic fistula (head trauma, barotrauma)
Seconds Yes Uncommon Peripheral
Vascular Ischemia,TIA Seconds to hours Usualy not Uncommon Central or peripheral
Meniere’s disease Hours yes Common Peripheral
Syphillis Hours yes Uncommon central
Vertiginous migraine Hours No Common Central
Labyrinthitis Days Yes Common Peripheral
Vascular Ischemia: Stroke Days Usually not Uncommon Central or peripheral
Vestibular neuronitis Days No Common Peripheral
Anxiety disorder Variable Usually not Common Unspecified
Acoustic neuroma months yes Uncommon Peripheral
Multiple sclerosis Months no uncommon central
Vestibular ototoxicity months yes uncommon peripheral
Dix-Hallpike ManeuverDix-Hallpike Maneuver
Epley ManeuverEpley Maneuver
Internet resources for patient education
Internet resources for patient education
http://www.youtube.com/watch?v=hhinu_oU_hM
http://www.youtube.com/watch?v=NQr7MKJBAJY
http://www.youtube.com/watch?v=eOuzUi5ckrk
http://www.youtube.com/watch?v=hhinu_oU_hM
http://www.youtube.com/watch?v=NQr7MKJBAJY
http://www.youtube.com/watch?v=eOuzUi5ckrk
THANKS !THANKS !
ReferencesReferences
Labuguen R. Initial Evaluation of Vertigo. American Family Physician. January 15, 2006.
Swartz R, Longwell P. Treatment of Vertigo. American Family Physician. March 15, 2005.
Labuguen R. Initial Evaluation of Vertigo. American Family Physician. January 15, 2006.
Swartz R, Longwell P. Treatment of Vertigo. American Family Physician. March 15, 2005.