An Approach to the
Patient with Vertigo
Cynthia Phelan PGY 1
2003 10 23
Vertigo
A false sense of moving or spinning or of
objects moving or spinning, usually
accompanied by nausea and loss of
balance.
Chief Complaint: “Dizziness”
Vertigo
Light Headedness
Weakness
Faintness
Mental Confusion
Headache
Gait disorder
Paresthesias
Abnormalities of Auditory Canal
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Benign Paroxysmal Positional Vertigo
Labyrinthitis
Otitis Interna
Herpes zoster
Meniere`s disease
Vestibular nerve inflammation
Trauma
Neurologic
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•
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Multiple sclerosis
Neoplasm
Migraine
Circulatory
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CVA
Vertebrobasilar insufficiency
Trauma

Skull # with labyrinth injury
Psychiatric
•
Panic disorder
Pharmacological
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Alcohol
Aminoglycosides
Illicit drugs
Environmental
•
Motion sickness
History
Description of symptoms
Timing

Onset, duration, frequency, diurnal variation
Positional Dependence
Associated symptoms
Alleviating and Aggravating Factors
Past Medical History
Medications
Recent trauma.
Risk Factors for Causes of Central Vertigo
Physical Exam
Vitals
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Pay attention to BP (orthostatic) and Pulse
HEENT
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EOMs - NYSTAGMUS
Hearing
CVS

Rate, rhythm, bruits, murmurs
Neurologic
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Cranial nerves
Reflexes
Cerebellar Exam
Gait
Proprioception
Peripheral Vertigo
Central Vertigo
Associated Symptoms
 Nausea & vomiting, diaphoresis
Associated Symptoms - Neurologic
 Diplopia, dysphagia, facial numbness,
ataxia, hemiparesis
Auditory Complaints - tinnitus, hearing loss
Auditory Complaints - infrequent
Intense Symptoms
Less Intense Symptoms
Abrupt onset
Gradual Onset
Association with head trauma
Not Usually Associated with Head Trauma
Nystagmus
 Horizontal or Rotary
  by gaze fixation
 Direction constant
Nystagmus
 Vertical or Multidirectional
  by gaze fixation
 Varies with direction of gaze
Causes of Peripheral Vertigo
•
BPV
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Due to deposition of calcium carbonate crystals in
the posterior semi-circular canal
Repeated attacks of vertigo lasting a few seconds
Aggravated by changes in posture, typically turning
ones head while lying in bed
No hearing loss or tinnitus
Usual onset in the 60s – 70s
Dix-Hallpike diagnostic and often therapeutic
Rotary nystagmus

Rx – Gravol, eply maneuver
Causes of Peripheral Vertigo
• Labyrithitis
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Viral infection of labyrinth, rarely associated with otitis media
Severe vertigo associated with hearing loss
Tx - Self limited, Gravol, decongestants
• Meniere`s Disease
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Due to endolymphatic system dilation and degeneration of
cochlear hair cells.
Recurrent attacks of severe vertigo, vomiting and tinnitus
Associated with progressive deafness
Typical presentation is patient with progressive hearing loss who
develops sudden severe attacks of vertigo which last for 30min
to several hours before abating
severity and frequency of attacks decrease as deafness
increases
Tx - Bed rest acutely, ENT, surgical ablation of labyrinth
Peripheral Vertigo
•
Vestibular Neuronitis
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Illness of suspected viral origin, may be mild encephalitis
usually follows URTI
Vertigo without hearing loss +/- tinnitus
Abnormal caloric testing
Tx - Time limited, residual symptoms may last for weeks.
Vestibulococclear Nerve Lesions, CP angle tumors
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Acoustic schwannomas, meningiomas
Preceded by hearing loss, associated neurologic symptoms ipsilateral corneal reflex impairment, facial weakness,
cerebellar signs
Patients complain of unsteadiness more than vertigo
Tx – Neurology / Neurosurgery consult
Causes of Central Vertigo
1.
Cerebellar Hemorrhage or infarction
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2.
Vertigo, ataxia, headache
May have conjugate eye deviation to the opposite side of the lesion
Patients unable to maintain body position
Neurology consult and MRI/CT head STAT
Brainstem
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3.
Infarction or hemorrhage of brainstem produces vertigo as one of a
large constellation of symptoms...dysphagia, dysphonia, facial
numbness, absent corneal reflex, ipsilateral Horner`s, deficits in CN
VI, VII, VIII.
STAT neurology/neurosurgery consult…often little can be done for
these patients
Prognosis poor
Multiple Sclerosis
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Vertigo can be produced by demyelinating lesions in the brainstem
Vertigo is the presenting symptom in 5% of cases
MISC
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Disequilibrium Syndrome
ill-defined dizziness resulting from multiple sensory
abnormalities
Usually in elderly
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Hyperventilation Syndrome
Anxiety
Near Syncope, hypoglycemia
Migraine Aura
Drugs / Ototoxins
Aminoglycosides, saliculates, ethanol, phenytoin, quinine,
benzene, arsenic
Treatment
Therapy depends on the etiology of the vertigo.
1. Symptomatic relief
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Rehydration - esp. in patients with vomiting and the elderly
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Bed rest in comfortable position
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Medications for symptomatic relief
antihistamines, anticholinergics, antiemetics and
benzodiazapies
2. Eply Maneuver for BPPV
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First Dix-Hallpike test performed – patient’s head rotated 45
degrees to the right
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Once nystagmus stops, rotate head until body is face down (hold
10-15 sec)
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Bring patient back to seated position with head turned over left
shoulder
 80% success rate in BPV
3. Reassurance…symptoms of vertigo though distressing are usuall
benign and self limited.
Take Home Points
1. Determine what the patient’s symptoms
truly are – vertigo vs lightheadedness
2. Central vs Peripheral origin
3. Symptomatic treatment for benign, selflimited conditions
4. Referral for any suspected intracranial
lesions