Vertigo

Vertigo is defined as the perceived sensation of rotational motion while remaining still. A very common complaint in primary care and the ER, vertigo is more frequently experienced by women and its prevalence increases with age. Vertigo is classified into peripheral or central based on its etiology. Vertigo is a clinical diagnosis, differentiated through history and physical examination findings, most notably nystagmus. Further testing may be required in malignant cases. Management depends on the etiology but certain maneuvers such as the Epley maneuver can be diagnostic and therapeutic.

Last update:

Editorial responsibility: Stanley Oiseth, Lindsay Jones, Evelin Maza

Table of Contents

Share this concept:

Share on facebook
Share on twitter
Share on linkedin
Share on reddit
Share on email
Share on whatsapp

Overview

Definition

Vertigo is a clinical symptom described as the perceived sensation of rotational motion while remaining still.

Epidemiology

  • The prevalence of vertigo increases with age.
  • Accounts for > 50% of the presenting complaints of “dizziness” in the ED
  • Women are 2–3 times more likely to report vertigo than men.
  • Associated with depression and cardiovascular disease

Classification

  • Peripheral: due to pathology of the vestibular labyrinth or vestibular nerve
  • Central: due to pathology of the brainstem or cerebellum Cerebellum The cerebellum, Latin for "little brain," is located in the posterior cranial fossa, dorsal to the pons and midbrain, and its principal role is in the coordination of movements. The cerebellum consists of 3 lobes on either side of its 2 hemispheres and is connected in the middle by the vermis. Cerebellum

Etiology

Peripheral:

  • Benign paroxysmal positional vertigo (BPPV) (93% of cases)
  • Acute labyrinthitis (due to viral infection)
  • Ménière‌ ‌disease
  • Vestibular neuritis
  • Ramsay Hunt syndrome (also known as herpes zoster Herpes Zoster Varicella-zoster virus (VZV) is a linear, double-stranded DNA virus in the Herpesviridae family. Shingles (also known as herpes zoster) is more common in adults and occurs due to the reactivation of VZV. Varicella-Zoster Virus/Chickenpox oticus)
  • Cholesteatomas
  • Otosclerosis
  • Otomastoiditis
  • Perilymphatic fistula
  • Vestibular schwannoma Vestibular schwannoma Acoustic neuroma, also referred to as vestibular schwannoma, is a benign tumor arising from Schwann cells of the vestibular component of the cranial nerve VIII. Acoustic neuroma forms within the internal auditory meatus and extends into the cerebellopontine angle. Acoustic Neuroma

Central:

  • Ischemic or hemorrhagic strokes
  • CNS tumors (cerebellopontine angle):
    • Meningioma Meningioma Meningiomas are slow-growing tumors that arise from the meninges of the brain and spinal cord. The vast majority are benign. These tumors commonly occur in individuals with a history of high doses of skull radiation, head trauma, and neurofibromatosis 2. Meningioma
    • Brainstem glioma
    • Medulloblastoma Medulloblastoma Medulloblastomas are malignant primitive neuroectodermal tumors that arise in the posterior fossa in children. Medulloblastomas are the most common malignant brain tumors in children. Patients with medulloblastoma present with symptoms of increased intracranial pressure and cerebellar signs, which both evolve and worsen over weeks to a few months. Medulloblastoma
    • Metastases
  • Vestibular migraines
  • Medication-induced vertigo (e.g., phenytoin and salicylates)

Both: multiple sclerosis Multiple Sclerosis Multiple sclerosis (MS) is a chronic inflammatory autoimmune disease that leads to demyelination of the nerves in the CNS. Young women are more predominantly affected by this most common demyelinating condition. Multiple Sclerosis

Pathophysiology

To understand the causes of vertigo, it is important to understand how the human body perceives and maintains balance.

  • Vestibular nuclei receive a signal corresponding to the acceleration of the head.
    • The signal is carried to cranial nerves Cranial nerves There are 12 pairs of cranial nerves (CNs), which run from the brain to various parts of the head, neck, and trunk. The CNs can be sensory or motor or both. The CNs are named and numbered in Roman numerals according to their location, from the front to the back of the brain. Overview of the Cranial Nerves (CNs) III, IV, and VI → coordination of the movements of the eyes and head
    • Eyes move in a direction opposite to that of head rotation to maintain fixation.
  • Semicircular canals are involved with rotational acceleration.
    • When the head is rotated, endolymph courses through the semicircular canals.
    • Endolymph causes the cupula, which encases the hair cells, to bend in a direction opposite to that of the rotation.
    • While bending, hair cells depolarize or hyperpolarize → transmission of the signal corresponding to the rotational movement via the vestibular pathway of CN VIII to the vestibular nuclei
    • Once the endolymph reaches the same rate of acceleration as that of the rotation of the head, the cupula returns to the upright position and signal transmission stops.
  • Otolith organs are involved with linear and horizontal acceleration.
    • Head begins to accelerate in a linear direction → otoliths embedded within the endolymph are displaced in the opposite direction
    • Displacement of the otoliths makes the endolymph accelerate with them → hair cells underneath bend → hair cells depolarize or hyperpolarize
    • Results in the generation of a signal carried by the vestibular pathway of CN VIII to the vestibular nuclei
    • Once the endolymph reaches the same rate of acceleration as the rest of the head, the stereocilia of hair cells return to the upright position and signal transmission stops.

History of Present Illnesses

Chief complaint

The chief complaint is dizziness.

  • Affected individuals may misidentify a feeling of lightheadedness, near-fainting, or a lack of balance as “vertigo.”
  • Ask: “Does it feel like the room is spinning around you?”

Duration and frequency

  • A few minutes or less: BPPV
  • Minutes to hours: vestibular migraine Migraine Migraine headache is a primary headache disorder and is among the most prevalent disorders in the world. Migraine is characterized by episodic, moderate to severe headaches that may be associated with increased sensitivity to light and sound, as well as nausea and/or vomiting. Migraine Headache, transient ischemic attack Transient ischemic attack Transient ischemic attack (TIA) is a temporary episode of neurologic dysfunction caused by ischemia without infarction that resolves completely when blood supply is restored. Transient ischemic attack is a neurologic emergency that warrants urgent medical attention. Transient Ischemic Attack (TIA) ( TIA TIA Transient ischemic attack (TIA) is a temporary episode of neurologic dysfunction caused by ischemia without infarction that resolves completely when blood supply is restored. Transient ischemic attack is a neurologic emergency that warrants urgent medical attention. Transient Ischemic Attack (TIA))
  • Hours or longer: vestibular neuritis, stroke

Associated symptoms

  • Nausea and vomiting: common and nonspecific
  • Focal neurologic deficits: indication of vertebrobasilar stroke or multiple sclerosis Multiple Sclerosis Multiple sclerosis (MS) is a chronic inflammatory autoimmune disease that leads to demyelination of the nerves in the CNS. Young women are more predominantly affected by this most common demyelinating condition. Multiple Sclerosis
  • Cardiovascular risk factors (stroke): diabetes, hypertension Hypertension Hypertension, or high blood pressure, is a common disease that manifests as elevated systemic arterial pressures. Hypertension is most often asymptomatic and is found incidentally as part of a routine physical examination or during triage for an unrelated medical encounter. Hypertension, and hyperlipidemia
  • Headache with aura (e.g., photophobia): indicative of vestibular migraine Migraine Migraine headache is a primary headache disorder and is among the most prevalent disorders in the world. Migraine is characterized by episodic, moderate to severe headaches that may be associated with increased sensitivity to light and sound, as well as nausea and/or vomiting. Migraine Headache
  • Hearing loss Hearing loss Hearing loss, also known as hearing impairment, is any degree of impairment in the ability to apprehend sound as determined by audiometry to be below normal hearing thresholds. Clinical presentation may occur at birth or as a gradual loss of hearing with age, including a short-term or sudden loss at any point. Hearing Loss: may indicate Ménière disease Ménière disease Ménière disease is a condition characterized by episodes of vertigo, tinnitus, and hearing loss, likely caused by endolymphatic hydrops of the labyrinthine system in the inner ear. The risk factors include a family history of Ménière disease, preexisting autoimmune disorders, allergies, and trauma to the head or ear. Ménière Disease

Triggers

  • Positional changes
  • Pressure changes

Recent history

  • Recent use of medications:
    • Administration of aminoglycosides Aminoglycosides Aminoglycosides are a class of antibiotics including gentamicin, tobramycin, amikacin, neomycin, plazomicin, and streptomycin. The class binds the 30S ribosomal subunit to inhibit bacterial protein synthesis. Unlike other medications with a similar mechanism of action, aminoglycosides are bactericidal. Aminoglycosides:
      • Preference for the cochlea: neomycin, kanamycin, dihydrostreptomycin, and amikacin
      • Preference for the vestibular system: tobramycin, gentamicin, and streptomycin
    • Anticonvulsants: e.g., phenytoin
    • Salicylates: e.g., aspirin
  • Recent intoxication: alcohol
  • Trauma: recent trauma to the head

Clinical pearl

Vertigo may apparently “decrease” in severity over time, as the affected individual adapts over days to weeks following the onset.

Related videos

Physical Examination

The main goal of physical examination is to differentiate central from peripheral vertigo. If the affected individual additionally complains of hearing loss, “Weber” and “Rinne” tests should be performed.

General exam

  • Vital signs:
    • Blood pressure
    • Orthostatic blood pressure
    • Pulse
  • Neurologic exams must be used to screen for motor/sensory/coordination impairments.
  • Mental status assessment is also recommended.

Nystagmus

  • Fast and rhythmic “beating” of the eyes returning to the point of fixation after a slight drift
  • In peripheral lesions (and causes of vertigo): beating (fast phase) toward the affected site
    • Instructing the individual to look toward the affected side will increase the amplitude and frequency of nystagmus.
    • Can also present with torsion
    • Inhibited by visual fixation
  • In central lesions: beating in any direction
    • Not suppressed by visual fixation

Head impulse test

  • Eyes are fixed on a target and the examiner quickly turns the subject’s head by 15º to the side.
  • Normal: Eyes remain on target.
  • Abnormal: Eyes drift off the target to later return with a saccade.
    • Indicates deficient vestibulo-ocular reflex → peripheral lesion
Diagram of an abnormal and normal head impulse test

Diagram of abnormal (above) and normal (below) head impulse tests:
Notice that in abnormal situations, the individual’s focal point shifts with the head to later return to the initial point of focus with a saccade.

Image by Lecturio.

Skew deviation test

  • The examiner covers 1 eye of the individual for a few seconds.
  • Normal: The covered eye remains fixed when uncovered.
  • Abnormal: The covered eye shifts vertically when uncovered.
    • Indicates central lesion

Dix-Hallpike maneuver

  • The subject sits on an examination table and quickly adopts a supine position while the examiner supports their head (to the right or to the left) at a 20º angle below the edge of the bed.
  • The position is held for 30 seconds.
  • Normal: no symptoms of vertigo or nystagmus
  • Abnormal: Vertigo with/without nystagmus is evoked.
Dix-hallpike maneuver

Dix-Hallpike maneuver:
Both diagnostic and curative in benign paroxysmal positional vertigo (BPPV). The subject sits on an examination table and quickly adopts a supine position while the examiner supports their head (to the right or to the left) at a 20º angle below the edge of the bed. The position is held for 30 seconds. In individuals with BPPV, symptoms of vertigo with or without nystagmus become evident.

Image by Lecturio.

Romberg test

  • The subject stands with their feet together and with arms to the sides or crossed.
  • The subject is instructed to close their eyes for 30 seconds.
  • In peripheral lesions: leaning or falling toward the side of the lesion
  • In central lesions: Direction of the lean or fall is variable Variable Variables represent information about something that can change. The design of the measurement scales, or of the methods for obtaining information, will determine the data gathered and the characteristics of that data. As a result, a variable can be qualitative or quantitative, and may be further classified into subgroups. Types of Variables, and some affected individuals may not be able to stand without assistance.

Diagnostic Evaluation

Vertigo itself is a clinical diagnosis. Further studies are only carried out if more malignant etiologies are suspected.

Neuroimaging

  • Indicated in suspicion of a central lesion (e.g., stroke, focal neurologic deficits, headache)
  • MRI: preferred modality
  • CT:
    • When MRI is not available or contraindicated
    • When thin cuts focusing on the brainstem and cerebellum Cerebellum The cerebellum, Latin for "little brain," is located in the posterior cranial fossa, dorsal to the pons and midbrain, and its principal role is in the coordination of movements. The cerebellum consists of 3 lobes on either side of its 2 hemispheres and is connected in the middle by the vermis. Cerebellum are needed

Audiogram

  • Performed by an audiologist or an otolaryngologist
  • Indicated in any individual with unilateral or bilateral hearing loss

Vestibular testing

  • Also called videonystagmography
  • Measures nystagmus via ocular, positional, and caloric testing
  • Used to confirm inner ear pathology

Management

Definitive management depends on the etiology.

Pharmacological management

  • Focused on symptomatic relief:
    • Antihistamines Antihistamines Antihistamines are drugs that target histamine receptors, particularly H1 and H2 receptors. H1 antagonists are competitive and reversible inhibitors of H1 receptors. First-generation antihistamines cross the blood-brain barrier and can cause sedation. Antihistamines
    • Benzodiazepines Benzodiazepines Benzodiazepines work on the gamma-aminobutyric acid type A (GABAA) receptor to produce inhibitory effects on the CNS. Benzodiazepines do not mimic GABA, the main inhibitory neurotransmitter in humans, but instead potentiate GABA activity. Benzodiazepines
    • Antiemetics Antiemetics Antiemetics are medications used to treat and/or prevent nausea and vomiting. These drugs act on different target receptors. The main classes include benzodiazepines, corticosteroids, atypical antipsychotics, cannabinoids, and antagonists of the following receptors: serotonin, dopamine, and muscarinic and neurokinin receptors. Antiemetics

Nonpharmacological management

  • Vestibular rehabilitation: training on maintaining balance based on visual and proprioceptive clues
  • Lifestyle recommendations: avoiding caffeine and alcohol (in Ménière disease Ménière disease Ménière disease is a condition characterized by episodes of vertigo, tinnitus, and hearing loss, likely caused by endolymphatic hydrops of the labyrinthine system in the inner ear. The risk factors include a family history of Ménière disease, preexisting autoimmune disorders, allergies, and trauma to the head or ear. Ménière Disease), avoiding triggers
  • Canalith repositioning procedure: Epley maneuver can be curative in individuals with BPPV.
  • For debilitating symptoms, surgical procedures or intratympanic gentamicin injections may be used.

Complications

  • High risk for falls!
  • Some affected individuals may require home-safety evaluation and supervision.
A diagram of epley maneuver (bppv)

Diagram showing the Epley maneuver for the management of benign paroxysmal positional vertigo (BPPV):
Each position is carried out as shown while being held for 30 seconds.
PSC PSC Primary sclerosing cholangitis (PSC) is an inflammatory disease that causes fibrosis and strictures of the bile ducts. The exact etiology is unknown, but there is a strong association with IBD. Patients typically present with an insidious onset of fatigue, pruritus, and jaundice, which can progress to cirrhosis and complications related to biliary obstruction. Primary Sclerosing Cholangitis: posterior semicircular canal
UT: utricle

Image by Lecturio.

Clinical Relevance

The following conditions can cause dizziness similar to vertigo:

  • Syncope Syncope Syncope is a short-term loss of consciousness and loss of postural stability followed by spontaneous return of consciousness to the previous neurologic baseline without the need for resuscitation. The condition is caused by transient interruption of cerebral blood flow that may be benign or related to a underlying life-threatening condition. Syncope: a short-term loss of consciousness caused by inadequate cerebral blood flow. Syncope Syncope Syncope is a short-term loss of consciousness and loss of postural stability followed by spontaneous return of consciousness to the previous neurologic baseline without the need for resuscitation. The condition is caused by transient interruption of cerebral blood flow that may be benign or related to a underlying life-threatening condition. Syncope has a wide range of etiologies. Affected individuals may have prodromal symptoms associated with imminent syncope or presyncope, such as lightheadedness, sweating, palpitations, nausea, feeling warm or cold, and blurred vision. Diagnosis is clinical, and management involves the identification and treatment of the underlying disorders.
  • Anemia Anemia Anemia is a condition in which individuals have low Hb levels, which can arise from various causes. Anemia is accompanied by a reduced number of RBCs and may manifest with fatigue, shortness of breath, pallor, and weakness. Subtypes are classified by the size of RBCs, chronicity, and etiology. Anemia: Overview: a condition characterized by low hemoglobin levels that can arise due to various causes. Anemia Anemia Anemia is a condition in which individuals have low Hb levels, which can arise from various causes. Anemia is accompanied by a reduced number of RBCs and may manifest with fatigue, shortness of breath, pallor, and weakness. Subtypes are classified by the size of RBCs, chronicity, and etiology. Anemia: Overview is accompanied by a reduced RBC count and may manifest with fatigue, lightheadedness, shortness of breath, pallor, and weakness. Diagnosis is made based on CBC and peripheral blood smear. Management involves treatment of the underlying disorder and transfusion in severe cases.
  • Ménière disease Ménière disease Ménière disease is a condition characterized by episodes of vertigo, tinnitus, and hearing loss, likely caused by endolymphatic hydrops of the labyrinthine system in the inner ear. The risk factors include a family history of Ménière disease, preexisting autoimmune disorders, allergies, and trauma to the head or ear. Ménière Disease: a disorder of the inner ear characterized by hearing loss, fluctuating aural symptoms (e.g., tinnitus), and spontaneous episodes of vertigo. Diagnosis is made based on a thorough history and physical examination, including a full otologic exam. An audiogram is also a key component of the evaluation. Management is centered around noninvasive techniques to maintain function; however, there is no cure.
  • Multiple sclerosis: a chronic inflammatory autoimmune disease leading to demyelination of the CNS. The clinical presentation varies widely depending on the site of lesions, but typically involves neurological symptoms affecting vision, motor function, sensation, and autonomic function. Management involves corticosteroids for acute exacerbations and disease-modifying agents to reduce exacerbations and slow disease progression.
  • Ischemic stroke Ischemic Stroke An ischemic stroke (also known as cerebrovascular accident) is an acute neurologic injury that occurs as a result of brain ischemia; this condition may be due to cerebral blood vessel occlusion by thrombosis or embolism, or rarely due to systemic hypoperfusion. Ischemic Stroke: also known as a cerebrovascular accident Cerebrovascular accident An ischemic stroke (also known as cerebrovascular accident) is an acute neurologic injury that occurs as a result of brain ischemia; this condition may be due to cerebral blood vessel occlusion by thrombosis or embolism, or rarely due to systemic hypoperfusion. Ischemic Stroke (CVA), ischemic stroke is an acute neurologic injury resulting from brain ischemia. The clinical presentation includes neurologic symptoms with varying degrees of motor and sensory loss, which corresponds to the area of the brain affected and the extent of tissue damage. Management is with the timely restoration of blood flow and prevention of a 2nd stroke.
  • Wernicke encephalopathy Wernicke encephalopathy Wernicke encephalopathy is an acute, reversible condition that is caused by severe thiamine deficiency. This condition is most commonly seen in alcohol abusers. The classic triad of symptoms is encephalopathy, oculomotor dysfunction, and gait ataxia, although all 3 features are only present in one-third of patients. Wernicke Encephalopathy and Korsakoff Syndrome: an acute, reversible condition caused by severe thiamine deficiency. Wernicke encephalopathy Wernicke encephalopathy Wernicke encephalopathy is an acute, reversible condition that is caused by severe thiamine deficiency. This condition is most commonly seen in alcohol abusers. The classic triad of symptoms is encephalopathy, oculomotor dysfunction, and gait ataxia, although all 3 features are only present in one-third of patients. Wernicke Encephalopathy and Korsakoff Syndrome is most commonly seen in individuals with severe alcohol-use disorder and is characterized by the classic triad of encephalopathy, oculomotor dysfunction, and gait ataxia, although all 3 features are only present in ⅓ of the affected population. Diagnosis is made clinically. Management includes thiamine supplementation and recommendations for alcohol cessation.

References

  1. Stanton, M., Freeman, A.M. (2021). Vertigo. StatPearls. Treasure Island (FL): StatPearls Publishing. Retrieved September 15, 2021, from http://www.ncbi.nlm.nih.gov/books/NBK482356/ 
  2. Barrett, K.E., Barman, S.M., Boitano, S., Reckelhoff, J.F. (2017). Hearing & Equilibrium. In Ganong’s Medical Physiology Examination and Board Review. McGraw-Hill Education. Retrieved September 15, 2021, from http://accessmedicine.mhmedical.com/content.aspx?aid=1142554680 
  3. Wipperman, J. (2021). Dizziness and Vertigo. In Kellerman, R.D., Rakel, D.P. (Eds.), Conn’s Current Therapy 2021, pp. 9–14. Elsevier. Retrieved September 15, 2021, from https://www.clinicalkey.es/#!/content/book/3-s2.0-B9780323790062000045 
  4. Walker, M.F., Daroff, R.B. (2018). Dizziness and vertigo. Jameson, J., et al. (Eds.), Harrison’s Principles of Internal Medicine, 20 ed. McGraw Hill. Retrieved September 14, 2021, from https://accessmedicine.mhmedical.com/content.aspx?sectionid=192011330&bookid=2129&Resultclick=2
  5. Kerber, K. (2021). Dizziness. DeckerMed Medicine. Retrieved September 15, 2021, from doi:10.2310/PSYCH.6089
  6. Kroenke, K., Lucas, C.A., Rosenberg, M.L., et al. Causes of persistent dizziness. A prospective study of 100 patients in ambulatory care. Ann Intern Med. 1992, 117: pp. 898–904.

Study on the Go

Lecturio Medical complements your studies with evidence-based learning strategies, video lectures, quiz questions, and more – all combined in one easy-to-use resource.

Learn even more with Lecturio:

Complement your med school studies with Lecturio’s all-in-one study companion, delivered with evidence-based learning strategies.

User Reviews

0.0

()

¡Hola!

Esta página está disponible en Español.

🍪 Lecturio is using cookies to improve your user experience. By continuing use of our service you agree upon our Data Privacy Statement.

Details