From the Guidelines
Vertigo is a sensation of spinning or dizziness that can significantly impact daily life, and for immediate relief, medications like meclizine (25mg every 6-8 hours), diazepam (2-5mg every 8 hours), or promethazine (25mg every 6 hours) can help manage symptoms, as noted in the clinical practice guideline for Meniere's disease 1.
Causes of Vertigo
The causes of vertigo can be diverse, including inner ear problems like benign paroxysmal positional vertigo (BPPV), vestibular neuritis, or Meniere's disease, as well as migraines, medication side effects, or rarely, neurological conditions 1.
- BPPV results from mobile debris (canaliths) in the vestibular labyrinth and can be diagnosed with the Dix-Hallpike maneuver.
- Vestibular neuritis is a viral infection of the vestibular system, leading to acute prolonged vertigo.
- Meniere's disease is characterized by spontaneous vertigo attacks with documented low- to midfrequency sensorineural hearing loss in the affected ear.
Diagnosis and Treatment
For persistent vertigo, the Epley maneuver is effective for BPPV, which involves a series of head movements to reposition displaced calcium crystals in the inner ear 1.
- Vestibular rehabilitation exercises can also help the brain compensate for balance problems.
- It is essential to differentiate between peripheral causes of vertigo and central nervous system (CNS) causes, as CNS causes can be indicative of more serious conditions such as stroke or intracranial tumors 1.
- Imaging evaluation is not necessary for typical BPPV but may be required for atypical cases or those with suspected CNS causes.
Management and Prevention
To manage vertigo, it is recommended to:
- Stay hydrated
- Avoid sudden head movements
- Sit or lie down when experiencing an episode
- Consider vestibular rehabilitation exercises to improve balance and reduce symptoms If vertigo persists beyond a few days, is accompanied by hearing loss, severe headache, or difficulty walking, seek medical attention promptly as these may indicate a more serious condition requiring specialized treatment 1.
From the Research
Causes of Vertigo
- The causes of vertigo are most commonly otological, followed by central, somatosensory, and visual 2
- Benign paroxysmal positional vertigo (BPPV) is a common cause of peripheral vertigo 2, 3
- Other causes of peripheral vertigo include Meniere's disease, vestibular neuronitis, labyrinthitis, and a perilymph fistula 2
Diagnosis of Vertigo
- A robust systematic approach can usually arrive at the diagnosis of vertigo 2
- The first question in approaching patients with dizziness is to categorise dizziness into one of the four groups: lightheadedness, pre-syncope, disequilibrium, and vertigo 2
- Central vertigo has to be differentiated with peripheral vertigo 2
- Physical examination findings such as limb weakness/hemiparesis, truncal/gait ataxia, dysmetria signs, head impulse test (HIT), spontaneous nystagmus, nystagmus type, and test of skew can help diagnose central vertigo 4
Treatment of Vertigo
- The Epley maneuver is more effective than vestibular rehabilitation at 1-week follow-up in treating posterior benign paroxysmal positional vertigo (p-BPPV) 5
- Canalith repositioning maneuvers (Semont, Epley, and Gufoni's maneuvers) are level 1 evidence treatment for BPPV 3
- The choice of maneuver is up to the clinician's preferences, failure of the previous maneuver, or movement restrictions of the patient 3
- Vestibular rehabilitation and the Epley maneuver are equally effective at 1-month follow-up in treating p-BPPV 5
- Canalith repositioning maneuver is a treatment option for BPPV and shows promise in a pilot study 6