What are the causes of vertigo (dizziness)?

From the Guidelines

Vertigo should be managed by first identifying the underlying cause, with a focus on differentiating it from other conditions such as Ménière's disease, benign paroxysmal positional vertigo (BPPV), and vestibular migraine, as outlined in the clinical practice guideline for Ménière's disease 1. To approach vertigo, it's crucial to understand that it is a sensation of spinning or dizziness that can significantly impact daily life. The management of vertigo involves a thorough history and physical examination to evaluate for neurologic, otologic, oncologic, inflammatory, or infectious causes.

Key Considerations

• The history and physical examination should evaluate for neurologic (ie, stroke, migraine), other neurotologic/otologic (ie, cerebellopontine angle [CPA] tumors, benign paroxysmal positional vertigo [BPPV]), oncologic, inflammatory, or infectious or vascular causes, as suggested by the clinical practice guideline for Ménière's disease 1.
• It is essential to ensure that the patient is describing actual vertigo (sense of rotation or spinning), which is the hallmark symptom of inner ear dysfunction, including Ménière's disease.
• A confident description of spinning is typically specific for inner ear dysfunction and Ménière's disease.
• Clinicians should ask patients detailed/specific questions about the vertigo attacks, including the nature of the onset (spontaneous or provoked), duration of active vertigo (seconds, minutes, hours, or entire day), and concurrent otologic symptoms (fluctuating hearing, tinnitus, aural fullness) just before, during, or after the vertigo attack.

Management Strategies

• For immediate relief, medications like meclizine (25mg every 6-8 hours), diazepam (2-5mg as needed), or promethazine (12.5-25mg every 4-6 hours) can help manage symptoms, as they are commonly used in the treatment of vertigo.
• During an acute episode, sitting or lying down in a quiet, dark room, avoiding sudden head movements, and focusing on a stationary object can help alleviate symptoms.
• The Epley maneuver can be effective for vertigo caused by benign paroxysmal positional vertigo (BPPV), which involves a series of head position changes to relocate displaced inner ear crystals.
• Long-term management includes vestibular rehabilitation exercises to retrain the balance system, avoiding triggers like caffeine and alcohol, and staying hydrated.

When to Seek Medical Attention

• If vertigo persists beyond a few days, is severe, or is accompanied by hearing loss, severe headache, or neurological symptoms, it is crucial to seek medical attention as it could indicate a more serious condition requiring specific treatment, such as stroke or vestibular migraine, as differentiated in the guideline 1.

From the FDA Drug Label

MECLIZINE HYDROCHLORIDE tablets, for oral use Initial U. S. Approval: 1957 INDICATIONS AND USAGE Meclizine hydrochloride tablets are indicated for the treatment of vertigo associated with diseases affecting the vestibular system in adults (1).

Meclizine hydrochloride tablets are indicated for the treatment of vertigo associated with diseases affecting the vestibular system in adults 2.

• The recommended dosage is 25 mg to 100 mg daily, in divided doses.
• Key warnings include the potential for drowsiness and anticholinergic action.

From the Research

Definition and Classification of Vertigo

• Vertigo is a type of dizziness that is characterized by a sensation of spinning or rotation, and it can be classified into different categories based on its cause and symptoms 3, 4.
• The distinction between different types of dizziness, including vertigo, presyncope, disequilibrium, and light-headedness, is of limited clinical usefulness, and patients often have difficulty describing the quality of their symptoms 3, 4.

Causes of Vertigo

• Vertigo can be caused by a variety of factors, including peripheral and central etiologies, with peripheral etiologies being usually benign and central etiologies often requiring urgent treatment 3, 4.
• Benign paroxysmal positional vertigo (BPPV) is a common cause of vertigo, and it is characterized by episodic vertigo triggered by head motion 3, 5, 6.
• Other causes of vertigo include Meniere disease, vestibular neuritis, and labyrinthitis, and the tempo of the vertiginous attacks and other associated symptoms can help differentiate between these causes 3, 7.

Diagnosis and Treatment of Vertigo

• The diagnosis of vertigo involves a physical examination, including orthostatic blood pressure measurement, a full cardiac and neurologic examination, assessment for nystagmus, and the Dix-Hallpike maneuver 3, 4.
• The HINTS (head-impulse, nystagmus, test of skew) examination can help distinguish between peripheral and central etiologies of vertigo 3, 4.
• Treatment of vertigo depends on the underlying cause, and it may include canalith repositioning procedures, such as the Epley maneuver, vestibular rehabilitation, and pharmacologic intervention 3, 4, 5, 6.
• The Epley maneuver is a effective treatment for BPPV, and it has been shown to be more effective than vestibular rehabilitation in some studies 5, 6.