What are the causes of vertigo (dizziness)?

From the Guidelines

Vertigo is best managed with the Epley maneuver for benign paroxysmal positional vertigo (BPPV) and vestibular rehabilitation exercises to strengthen balance and reduce sensitivity to motion, as these interventions have been shown to improve quality of life and reduce symptoms 1. When experiencing vertigo, it is essential to sit or lie down in a quiet, dark room and avoid sudden head movements to alleviate symptoms.

• Medications like meclizine (25mg every 6-8 hours), diazepam (2-5mg every 8 hours), or promethazine (25mg every 6 hours) can help manage symptoms, but their use should be limited to acute episodes and under medical supervision 1.
• The Epley maneuver is a series of head position changes designed to relocate displaced inner ear crystals and is effective for BPPV, which accounts for approximately 85% to 95% of BPPV cases 1.
• Vestibular rehabilitation exercises can help prevent episodes by strengthening balance and reducing sensitivity to motion, and patients should be encouraged to stay hydrated, limit alcohol and caffeine, and get adequate sleep to prevent vertigo episodes 1.
• It is crucial to differentiate vertigo from other causes of dizziness, such as lightheadedness or presyncopal episodes, and to identify the underlying cause of vertigo, as some conditions, like Ménière's disease, may require specific treatment 1.
• A thorough otologic history and physical examination should be performed to evaluate for neurologic, otologic, or other causes of vertigo, and patients should be clinically educated to clearly define their symptoms and provide a reliable history 1.

From the Research

Definition and Diagnosis of Vertigo

• Vertigo is a common condition characterized by sudden, brief episodes of vertigo precipitated by specific head movements 2
• The diagnosis of vertigo can be established with a Dix-Hallpike maneuver for the posterior and anterior canals, or supine roll test for the horizontal canal, and typically does not require additional ancillary testing 2
• Clinical assessment aims to establish the presence of true vertigo, differentiate between vertigo of central or peripheral origins, and to evaluate the need for urgent investigations and referrals 3

Causes of Vertigo

• Peripheral causes of vertigo are more common, but central causes such as transient ischaemic attack or stroke should always be considered and ruled out appropriately 3
• Benign paroxysmal positional vertigo (BPPV) is the most common peripheral vestibular end-organ disease and a common cause of vertigo 4, 2
• Other causes of peripheral vertigo include Meniere's disease, vestibular neuronitis, labyrinthitis, and a perilymph fistula 5

Treatment of Vertigo

• The Epley maneuver is an effective way to treat posterior canal BPPV, the most common variant of BPPV 4, 2
• The Epley maneuver is more effective than vestibular rehabilitation at 1-week follow-up with regard to patient-reported symptom relief and conversion of the Dix-Hallpike maneuver from positive to negative 6
• Options for operative intervention are available for intractable cases or patients with severe and frequent recurrences of BPPV 2

Management of Vertigo

• The most efficient management of BPPV is to perform a bedside test (Dix-Hallpike test) and then to treat the patients with a bedside positional (the Epley) maneuver 4
• Application of these practices would improve important patient-centered outcomes such as symptom reduction, radiation exposure, side effects from medications, and less need for urgent follow-up with another health care provider 4