When patients describe feeling dizzy they may mean anything – presyncope, syncope, anxiety, weakness, vertigo or changes in mentation – so always clarify!
Vertigo implies the sensation of the movement when no movement is actually occurring (rotational or otherwise)
Causes
- Central –
- Vertebrobasillar insufficiency (will see cross neurological findings)
- Neoplastic
- Cerebellar disorders (hemorrhage, degeneration)
- Basal ganglia disorders
- MS
- Neurosyphilis , TB
- Epilepsy
- Migraine
- Cerebrovascular disease
- Peripheral –
- Benign paroxysmal position vertigo
- Larbrynthitis
- Vestibular neuronitis
- Ramsay Hunt syndrome (Zoster rash w/i ear canal; hearing loss, CNVII findings)
- Menière’s disease
- CN VIII leasions (acoustic neuroma)
- Otosclerosis
- Traumatic – post head injury
- Drug induced – aminoglycosides
Characteristics (points to ask on history) – adapted from Tintinalli’s Emergency Medicine: A Comprehensive Guide ’04
Peripheral | Central | |
Onset | Sudden | Sudden or gradual |
Severity | Intense spinning | Varied |
Pattern | Paroxysmal, intermittent | Constant |
Positional | Yes | Possible |
N/V/diaphoresis | Yes | Possible |
Nystagmus | Rotatory-vertical, horizontal | Vertical |
Fatigue of S&s | Yes | No |
Hearing loss or tinnitus | Possible | No |
AbN TM | Possible | No |
CNS S&s | No | Yes |
Medication used in treating vertigo
Antihistamines
Diphenhydramine (Benadryl) 25-50mg PO/IM/IV q4h
Meclizine (Antivert, Bonamine) 25mg PO q6-12h
Hydroxysine (Atarax) 25-50 mg PO q6h
Promethazine (Phenergan) 25mg PO/IM/PR q6-8h
Anticholinergics
Dimenhydrinate (Gravol) 50-100mg PO/IM/IV q4h
Scopolamine (Hyosine) 0.5mg patch behind ear every 3 days
Antiemetics
Metoclopramide (Maxeran) 10-20mg PO/IV q8h
Vasodilators
Betahistine (Serc) 8-16mg PO tid
Benign Paroxysmal Positional Vertigo
- Due to otoliths in the semicircular canals (most frequently the posterior) which accumulate and shift with head movement thus activating the hair cells causing neuronal activity
- Age of onset: 50s
- Females > Males
- Episodes last up to 1 minute
- Particular movements tend to set off the vertigo, which fatigues through out the day
- Associated nystagmus, and nausea/vomiting
- Diagnosis: Dix Hallpike maneuver
- Treatment: Epley maneuver, anticholinergics or antihistamines
Menière’s disease
- Due to increased endolymph within the inner ear
- Age of onset: 65+
- Females = Males
- Episodes last up to hours
- Associated with nausea/vomiting, tinnitus, decreased hearing, and sensation of fullness
- Diagnosis: put glycerol in the ear (which acts as an osmotic diuretic)
- Treatment: symptomatic with betahistine, antihistamines, diuretics (hydrochlorothiazide)
Vestibular neuronitis
- Viral infection
- Age of onset: any
- Can last up to day (no recurrence)
- May have associated symptoms of viral illness, may have unilateral tinnitus or loss of hearing or positional nystagmus
- Treatment: symptomatic with antihistamines and antiemetics
Labyrinthitis
- Infection of the labyrinth (i.e viral, bacterial)
- Age of onset: any
- Can last up to day (no recurrence)
- Associated hearing loss
- Treatment: symptomatic but if bacterial require antibacterials and may need to be admitted to ENT for drainage