Chapter 46: Dizziness/vertigo

When patients complain of ‘dizziness’, they can be using this term to describe many different phenomena, and hence a careful history is required to unravel the problem. Other patients may use different terms to explain the same sensation, for example, ‘giddiness’, ‘swimming in the head’, ‘my brain spinning’, ‘whirling’ and ‘swinging’.

‘Dizzy’ comes from an old English word, dysig, meaning foolish or stupid. Strictly speaking, it means unsteadiness or lightheadedness—without movement or motion or spatial disorientation.

‘Vertigo’, on the other hand, comes from the Latin vertere (to turn) and -igo for a condition. It should describe a hallucination of rotation of self or the surroundings in a horizontal or vertical direction.¹

The term ‘dizziness’, however, is generally used collectively to describe all types of equilibrium disorders and, for convenience, can be classified as shown in FIGURE 46.1.

Vertigo

Vertigo is defined as an episodic sudden sensation of circular motion of the body or of its surroundings or an illusion of motion, usually a rotatory sensation. Other terms used by the patient to describe this symptom include ‘everything spins’, ‘my head spins’, ‘the room spins’, ‘whirling’, ‘reeling’, ‘swaying’, ‘pitching’ and ‘rocking’. It is frequently accompanied by autonomic symptoms such as nausea, retching, vomiting, pallor and sweating.

Vertigo is characteristically precipitated by standing or turning the head or by movement. Patients have to walk carefully and may become nervous about descending stairs or crossing the road and usually seek support. Therefore the vertiginous patient is usually very frightened and tends to remain immobile during an attack.

Patients may feel as though they are being impelled by some outside force that tends to pull them to one side, especially while walking.

True vertigo is a symptom of disturbed function involving the vestibular system or its central connections. It invariably has an organic cause. Important causes are presented in TABLE 46.1, while FIGURE 46.2 illustrates central neurological centres that can cause vertigo.

Nystagmus is often seen with vertigo and, since 80–85% of causes are due to an ear problem, tinnitus and hearing disorders are also associated. In acute cases there is usually a reflex autonomic discharge producing sweating, pallor, nausea and vomiting.

Giddiness

Giddiness is a sensation of uncertainty or ill-defined lightheadedness. Other terms used by patients include ‘a swimming sensation’, ‘walking on air’ and ‘ground going beneath me’. It usually contains no elements of rotation, impulsion, tinnitus, deafness, nausea or vomiting.

The patient with giddiness, although fearful of falling or swooning, can nonetheless walk without difficulty if forced to do so.

Giddiness is a typical psychoneurotic symptom.

Syncopal episodes

Syncope may present as a variety of dizziness or lightheadedness in which there is a sensation of impending fainting or loss of consciousness. Common causes are cardiogenic disorders and postural hypotension, which are usually drug-induced.

Disequilibrium

Disequilibrium implies a condition in which there is a loss of balance or instability while walking, without any associated sensations of spinning. Other terms used to describe this include ‘unsteadiness on feet’, ‘the staggers’, ‘swaying feeling’ and ‘dizzy in the feet’.

Disequilibrium is usually of neurogenic origin.

A summary of the diagnostic strategy model is presented in TABLE 46.2.

Probability diagnosis

In medical school we gain the wrong impression that the common causes of dizziness or vertigo are the relatively uncommon causes, such as Ménière syndrome, aortic stenosis, Stokes–Adams attacks, cerebellar disorders, vertebrobasilar disease and hypertension. In the real world of medicine, one is impressed by how often dizziness is caused by relatively common benign conditions, such as hyperventilation associated with anxiety, simple syncope, postural hypotension due to drugs and old age, inner ear infections, wax in the ears, post head injury, motion sickness and alcohol intoxication. In most instances making the correct diagnosis (which, as ever, is based on a careful history) is straightforward, but finding the underlying cause of true vertigo can be very difficult.

The common causes of vertigo seen in general practice are benign paroxysmal positional vertigo (BPPV, so often related to cervical vertebral dysfunction), accounting for about 25% of cases, acute vestibulopathy (vestibular neuronitis) and vestibular migraine.

Viral labyrinthitis is basically the same as vestibular neuronitis, except that the whole of the inner ear is involved so that deafness and tinnitus arise simultaneously with severe vertigo. The most common causes of recurrent spontaneous vertigo are Ménière syndrome and vestibular migraine.

Serious disorders not to be missed

Neoplasia

The important serious disorders to keep in mind are space-occupying tumours, such as acoustic neuroma, medulloblastoma and other tumours (especially posterior fossa tumours) capable of causing vertigo, intracerebral infections and cardiovascular abnormalities.

It is important to bear in mind that the commonest brain tumour is a metastatic deposit from lung cancer.³

Acoustic neuroma

This uncommon tumour should be suspected in the patient presenting with the symptoms shown in the diagnostic triad below. Headache may occasionally be present.

Diagnosis is best clinched by high-resolution MRI. Audiometry and auditory evoked responses are also relevant investigations.

Cardiac disorders

Cardiac disorders that must be excluded for giddiness or syncope are the various arrhythmias, such as Stokes–Adams attacks caused by complete heart block, aortic stenosis and myocardial infarction.

Cerebrovascular causes

The outstanding cerebrovascular causes of severe vertigo are vertebrobasilar insufficiency and brain stem infarction. Vertigo is the commonest symptom of transient cerebral ischaemic attacks in the vertebrobasilar distribution.¹

Severe vertigo, often in association with hiccoughs and dysphagia, is a feature of the variety of brain stem infarctions known as the lateral medullary syndrome due to posterior inferior cerebellar artery (PICA) thrombosis. There is a dramatic onset of vertigo with cerebellar signs, including ataxia and vomiting. There are ipsilateral cranial nerve (brain stem) signs with contralateral spinothalamic sensory loss of the face and body. Diagnosis is by CT or MRI scanning.

Neurological causes

Important neurological causes of dizziness are multiple sclerosis and complex partial seizures.

The lesions of multiple sclerosis may occur in the brain stem or cerebellum. Young patients who present with a sudden onset of vertigo with ‘jiggly’ vision but without auditory symptoms should be considered as having multiple sclerosis. Five per cent of cases of multiple sclerosis present with vertigo.

Pitfalls

A list of conditions causing dizziness that may be misdiagnosed is presented in TABLE 46.2. Wax in the ear certainly causes dizziness, though its mechanism of action is controversial. Cough and micturition syncope do occur, although they are uncommon.

Ménière syndrome is a pitfall in the sense that it tends to be overdiagnosed.

Seven masquerades checklist

Of these conditions, drugs and vertebral dysfunction (of the cervical spine) stand out as important causes. Depression demands attention because of the possible association of anxiety and hyperventilation.

Diabetes mellitus has an association through the possible mechanisms of hypoglycaemia from therapy or from an autonomic neuropathy.

Drugs

Drugs usually affect the vestibular nerve rather than the labyrinth. Drugs commonly associated with dizziness are presented in TABLE 46.3.

Cervical spine dysfunction

It is not uncommon to observe vertigo in patients with cervical spondylosis or post cervical spinal injury. It has been postulated⁴ that this may be caused by the generation of abnormal impulses from proprioceptors in the upper cervical spine, or by osteophytes compressing the vertebral arteries in the vertebral canal. Some instances of BPPV are associated with disorders of the cervical spine.

Psychogenic considerations

This may be an important aspect to consider in the patient presenting with dizziness, especially if the complaint is giddiness or lightheadedness. An underlying anxiety, particularly agoraphobia and panic disorder, may be the commonest cause of this symptom in family practice and clinical investigation of hyperventilation may confirm the diagnosis. The possibility of depression must also be kept in mind.⁵ Many of these patients harbour the fear that they may be suffering from a serious disorder, such as a brain tumour or multiple sclerosis, or face an impending stroke or insanity. Appropriate reassurance to the contrary is often positively therapeutic for that patient.

The essentials of the diagnostic approach include careful attention to the history and physical examination, and judicious selection of specific office tests and special investigations.

History

It is important to get patients to explain the precise nature of the symptoms, even asking their opinion as to the cause of their dizziness.

Key questions

The following questions should be addressed:

• Is it vertigo or pseudovertigo?

• Symptom pattern:

  • — paroxysmal or continuous?

  • — effect of position and change of posture?

• Any aural symptoms? Tinnitus? Deafness?

• Any visual symptoms?

• Any neurological symptoms?

• Any nausea or vomiting?

• Any symptoms of psychoneurosis?

• Any recent colds?

• Any recent head injury (even trivial)?

• Any drugs being taken?

  • — alcohol?

  • — marijuana?

  • — hypotensives?

  • — psychotropics?

  • — other drugs?

Examination

A full general examination is appropriate with particular attention being paid to the cardiovascular and central nervous systems and the auditory and vestibular mechanisms.

Guidelines

Examination guidelines are:

1. ear disease:

   • auroscopic examination: ? wax ? drum

   • hearing tests

   • Weber and Rinne tests

2. the eyes:

   • visual acuity

   • test movements for nystagmus

3. cardiovascular system:

   • evidence of atherosclerosis

   • blood pressure: supine, standing, sitting

   • cardiac arrhythmias

4. cranial nerves:

   • 2nd, 3rd, 4th, 6th and 7th

   • corneal response for 5th

   • 8th—auditory nerve

5. the cerebellum or its connections:

   • gait

   • coordination

   • reflexes

   • Romberg test

   • finger nose test: ? past pointing

6. the neck, including cervical spine

7. general search for evidence of:

   • anaemia

   • polycythaemia

   • alcohol dependence

Office tests for dizziness

• Ask the patient to perform any manoeuvre that may provoke the symptom.

• Carry out head positional testing to induce vertigo and/or nystagmus (e.g. Hallpike manoeuvre in FIG. 46.3 or head impulse test/head thrust). Avoid if prominent spontaneous vertigo and nystagmus.

• Take blood pressure measurements in three positions.

• Perform forced hyperventilation (20–25 breaths per minute) for 2 minutes.

• Carry out palpation of carotid arteries and carotid sinus (with care).

Investigations

Appropriate laboratory tests should be selected from TABLE 46.4.

Diagnostic guidelines

• A sudden attack of vertigo in a young person following a recent URTI is suggestive of vestibular neuronitis.

• Dizziness is a common symptom in menopausal women and is often associated with other features of vasomotor instability.

• Phenytoin therapy can cause cerebellar dysfunction.

• Postural and exercise hypotension are relatively common in the older atherosclerotic patient.

• Acute otitis media does not cause vertigo but chronic otitis media can, particularly if the patient develops a cholesteatoma, which then erodes into the internal ear causing a perilymphatic fistula.

Dizziness is not a common symptom in children. Vertigo can have sinister causes and requires referral because of the possibility of tumours, such as a medulloblastoma. A study by Eviatar and Eviatar⁶ of vertigo in children found that the commonest cause was a seizure focus particularly affecting the temporal lobe. Other causes included psychosomatic vertigo, vestibular migraine and vestibular neuritis.

Apart from the above causes it is important to consider:

• infection (e.g. meningitis, meningoencephalitis, cerebral abscess)

• trauma, especially to the temporal area

• middle-ear infection

• labyrinthitis (e.g. mumps, measles, influenza)

• BPPV (short-lived attacks of vertigo in young children between 1 and 4 years of age: tends to precede adulthood migraine)⁷

• hyperventilation

• drugs—prescribed

• illicit drugs (e.g. cocaine, marijuana)

• cardiac arrhythmias

• alcohol toxicity

A common trap is the acute effect of alcohol in curious children who can present with the sudden onset of dizziness.

Dizzy turns in girls in late teens

• These are commonly due to blood pressure fluctuations.

• Give advice related to reducing stress, lack of sleep and excessive exercise.

• Reassure that it settles with age (rare after 25 years).

Dizziness is a relatively common complaint of the elderly. Common causes include postural hypotension related mainly to drugs prescribed for hypertension or other cardiovascular problems. Cerebrovascular disease, especially in the areas of the brain stem, is also relevant in this age group. True vertigo can be produced simply by an accumulation of wax in the external auditory meatus, being more frequent than generally appreciated.

Middle-ear disorder is also sometimes the cause of vertigo in an older person but disorder of the auditory nerve, inner ear, cerebellum, brain stem and cervical spine are common underlying factors.

Malignancy, primary and secondary, is a possibility in the elderly. The possibility of cardiac arrhythmias as a cause of syncopal symptoms increases with age.

Dizzy turns in elderly women

If no cause such as hypertension is found, advise them to get up slowly from sitting or lying, and to wear firm elastic stockings.

Acute vestibulopathy (vestibular failure)

Causes:

• vestibular neuritis

• stroke—AICA or PICA

Vestibular neuritis covers both vestibular neuronitis and labyrinthitis, which are considered to be a viral infection of the vestibular nerve and labyrinth respectively, causing a prolonged attack of vertigo that can last for several days and be severe enough to require admission to hospital.⁸

It is analogous to a viral infection of the 7th nerve causing Bell palsy. The attack is similar to Ménière syndrome except that there is no hearing disturbance.

Characteristic features

• single attack of vertigo without tinnitus or deafness

• usually preceding ‘flu-like’ illness

• mainly in young adults and middle age

• abrupt onset with vertigo, ataxia, nausea and vomiting

• generally lasts days to weeks

• examination shows lateral or unidirectional nystagmus—rapid component away from side of lesion (no hearing loss)

• caloric stimulation confirms impaired vestibular function

It is basically a diagnosis of exclusion.

Treatment

• Rest in bed, lying very still

• Gaze in the direction that eases symptoms

The following drugs can be used (see TABLE 46.5):

• prochlorperazine (Stemetil) 12.5 mg IM (if severe vomiting), but may slow recovery, or 5–10 mg (o) tds

• or

• promethazine 10–25 mg IM or slow IV then 10–25 mg (o) for 48 hrs

• or

• (recommended as best)

• diazepam (which decreases brain-stem response to vestibular stimuli)² 5–10 mg IM for the acute attack, then 5 mg (o) tds for 2–3 days

A short course of corticosteroids often promotes recovery (e.g. prednisolone 1 mg/kg (up to 100 mg) (o) daily in morning for 5 days, then taper over 15 days and cease).^1,10

Outcome

Both are self-limiting disorders and usually settle over 5–7 days or several weeks. Labyrinthitis usually lasts longer and during recovery rapid head movements may bring on transient vertigo.

Benign paroxysmal positional vertigo

BPPV is a common type of acute vertigo that is induced by changing head position—particularly tilting the head backwards, changing from a recumbent to a sitting position or turning to the affected side.

Features

• Affects all ages, especially the elderly

• The female to male ratio is 2:1

• Recurs periodically for several days

• Each attack is brief, usually lasts 10–60 seconds, and subsides rapidly

• Severe vertigo on getting out of bed

• Can occur on head extension and turning head in bed

• Attacks are not accompanied by vomiting, tinnitus or deafness (nausea may occur)

• In one large series 17% were associated with trauma, 15% with viral labyrinthitis, while about 50% had no clear predisposing factor other than age. One accepted theory of causation is that fine pieces of floating crystalline calcium carbonate deposits (otoconia) that are loose in the labyrinth settle in the posterior semicircular canal and generate endolymphatic movement.¹¹ It may also be a variation of cervical dysfunction.

• Diagnosis is confirmed by head position testing: head impulse (head thrust) test or Hallpike manoeuvre (refer to YouTube for these manoeuvres).¹² In the latter, from a sitting position, the patient’s head is rapidly taken to a head-hanging position 30° below the level of the couch—do three times, with the head (1) straight, (2) rotated to the right, (3) rotated to the left. Hold on for 30 seconds and observe the patient carefully for vertigo and nystagmus. There is a latent period of a few seconds before the onset of the symptoms—see FIGURE 46.3.

• Tests of hearing and vestibular function are normal

• There is usually spontaneous recovery in weeks (most return to regular activity after 1 week)

• Recurrences are common: attacks occur in clusters

Management

• Give appropriate explanation and reassurance

• Avoidance measures: encourage the patient to move in ways that avoid the attack

• Drugs are not recommended

• Special exercises

• Cervical traction may help

Patient-performed exercises. Most patients appear to benefit from exercise, such as the Brandt–Daroff procedure¹³ or the Cawthorne–Cooksey exercises⁹ that consist essentially of repeatedly inducing the symptoms of vertigo. Rather than resorting to avoidance measures, the patient is instructed to perform positional exercises to induce vertigo, hold this position until it subsides, and repeat this many times until the manoeuvre does not precipitate vertigo. The attacks then usually subside in a few days.

Therapist-performed exercises. Physical manoeuvres performed as an office procedure include the Epley and Semont manoeuvres.

Rarely surgical treatment is required; it involves occlusion of the posterior semicircular canal rather than selective neurectomy.

Ménière syndrome

This is caused by a build-up of endolymph.

• It is commonest in the 30–50 years age group.

• It is characterised by paroxysmal attacks of vertigo, tinnitus, nausea and vomiting, sweating and pallor, deafness (progressive).

• Onset is abrupt—patient may fall and then be bedridden for 1–2 hours. Patient doesn’t like moving head.

• Attacks last 30 minutes to several hours.

• There is a variable interval between attacks (twice a month to twice a year).

• Nystagmus is observed only during an attack (often to side opposite affected inner ear).

• Examination:

  • — sensorineural deafness (low tones)

  • — caloric test: impaired vestibular function

  • — audiometry: sensorineural deafness, loudness recruitment

  • — special tests

• There are characteristic changes in electrocochleography.

Treatment

The aim is to reduce endolymphatic pressure by reducing the sodium and water content of the endolymph.

Anticipation of attack (fullness, tinnitus):

• prochlorperazine 25 mg suppository

• or

• 30 g urea crystals in orange juice (preferably 30 minutes before in prodromal phase)

• Treatment:

• diazepam 5 mg IV ± prochlorperazine 12.5 mg IM. Consider betahistine 8 mg (o) tds if persistent or episodic or a diuretic e.g. hydrochlorothiazide 25 mg (o) daily

• Reassurance with a careful explanation of this condition to the patient, who often associates it with malignant disease

• Excess intake of salt, tobacco and coffee to be avoided

• A low-salt diet is the mainstay of treatment (<3 g per day)

• Alleviate abnormal anxiety by using stress management, meditation or possibly long-term sedation (fluid builds up with stress)

• Referral for neurological assessment

• Diuretic (e.g. hydrochlorothiazide/amiloride daily)—check electrolytes regularly

Surgery may be an option for intractable cases.

Vestibular migraine (migrainous vertigo)

Migraine is a relatively common cause of vertigo and often unrecognised because of its many guises. It should be strongly suspected if there is a past and/or family history of migraine and also where there is a history of recurrent bouts of spontaneous vertigo or ataxia that persist for hours or days in the absence of aural symptoms.¹⁵ Vertigo, which is usually not violent, may take the place of the aura that precedes the headache or may be a migraine equivalent whereby the vertigo replaces the symptoms of headache, which may be an inconspicuous feature in some cases. Nausea and vomiting may be present. Pizotifen or propranolol are recommended for prophylaxis.

• Vertigo of uncertain diagnosis, especially in children

• Possibility of tumour, or bacterial infection

• Vertigo in presence of suppurative otitis media despite antibiotic therapy

• Presumed viral labyrinthitis not abating after 3 months

• Vertigo following trauma

• Presumed Ménière syndrome, not responding to conservative medical management

• Evidence of vertebrobasilar insufficiency

• BPPV persisting for more than 12 months despite treatment with particle repositioning exercises

Hand-out sheets from Murtagh’s Patient Education 7th edition:

• Labyrinthitis

• Ménière syndrome

• Vertigo: benign positional vertigo

• Vertigo: exercises for benign positional vertigo