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 both immediate relief strategies and long-term management plans. 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 suggested by various clinical guidelines 1.

Key Considerations for Vertigo Management

• During an acute episode, it is recommended to sit or lie down in a safe place, avoid sudden head movements, and focus on a stationary object to reduce the sensation of spinning.
• For long-term management, vestibular rehabilitation exercises are effective - these include gaze stabilization, habituation exercises, and balance training performed daily for several weeks 1.
• The Epley maneuver can specifically help with BPPV, the most common cause of vertigo, by relocating the calcium particles in the inner ear that cause the vertigo symptoms.
• Lifestyle modifications like staying hydrated, limiting alcohol and caffeine, and getting adequate sleep can reduce the frequency of episodes.

Importance of Accurate Diagnosis

Vertigo typically results from inner ear problems where the vestibular system, which controls balance, sends incorrect signals to the brain about body position and movement. It is essential to differentiate vertigo from other conditions that may present with similar symptoms, such as lightheadedness or presyncopal episodes, which are not consistent with inner ear dysfunction or Ménière's disease 1. If symptoms persist beyond a few days, are severe, or are accompanied by hearing loss, facial weakness, or severe headache, a thorough medical evaluation is necessary to rule out more serious conditions such as stroke, infections, or tumors 1.

Clinical Evaluation

A thorough otologic history and physical examination should evaluate for neurologic, other neurotologic/otologic, oncologic, inflammatory, or infectious or vascular causes, as outlined in the clinical practice guideline for Ménière's disease 1. Clinicians should ask patients detailed and specific questions about the vertigo attacks, including the nature of the onset, duration of active vertigo, and concurrent otologic symptoms just before, during, or after the vertigo attack. This approach ensures that the management plan is tailored to the underlying cause of vertigo, thereby improving outcomes in terms of morbidity, mortality, and quality of life.

From the FDA Drug Label

Meclizine hydrochloride tablets are indicated for the treatment of vertigo associated with diseases affecting the vestibular system in adults (1). Recommended dosage: 25 mg to 100 mg daily, in divided doses (2.1).

• Vertigo treatment: Meclizine hydrochloride tablets are indicated for the treatment of vertigo associated with diseases affecting the vestibular system in adults 2.
• Dosage: The recommended dosage is 25 mg to 100 mg daily, in divided doses 2.
• Key consideration: Meclizine should be used with caution in patients with certain medical conditions, such as asthma, glaucoma, or enlargement of the prostate gland, due to its potential anticholinergic action 2.

From the Research

Definition and Classification of Vertigo

• Vertigo is defined as an abnormal sensation of body motion or of its surrounding objects 3
• It is classified as peripheral or central, according to its origin, and can also be occasionally mixed 3
• The most common cause of peripheral involvement is benign paroxysmal positional vertigo (BPPV) 3

Diagnosis of Vertigo

• The initial findings on clinical evaluation of patients are the clues for making a correct diagnosis 3
• The differentiation between central and peripheral vertigo can be optimized by analyzing nystagmus, by using the skew test and the head impulse test (HINTS), as also by performing the appropriate tests to evaluate the integrity of the vestibular-cerebellar pathway 3
• Tonal threshold audiometry could raise the diagnostic sensibility from 71 to 89% on initial approach 3

Treatment of Vertigo

• 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 in patients with posterior BPPV 4
• There is inconsistent evidence for the effectiveness of the Epley maneuver compared with vestibular rehabilitation at 1-month follow-up 4
• The Epley maneuver is beneficial in treating BPPV, with symptoms subsiding within 72 hours in 35% and within a week in 74% of patients after one session of treatment 5
• The Epley maneuver should be considered in all patients with posterior canal BPPV, with a clinically relevant effect in favor of the Epley maneuver regarding symptom relief at 1-week follow-up 6