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.