What is vertigo and how is it managed in patients, particularly older adults, with a history of similar symptoms, recent head injuries, or infections?

Definition and Clinical Understanding of Vertigo

Vertigo is a sensation of self-motion (typically rotary spinning) or movement of the environment when neither is actually occurring, or the sensation of distorted self-motion during an otherwise normal head movement. 1

Core Distinguishing Features

Vertigo must be differentiated from other forms of dizziness, as this distinction fundamentally guides diagnostic and therapeutic decisions:

• True vertigo involves a specific illusion of rotational movement—either the patient spinning or the environment spinning around them 1, 2
• Dizziness is a less specific term that may indicate disequilibrium, light-headedness, or presyncope, but lacks the rotational quality 1
• Imbalance represents a sense of unsteadiness or instability that is discrete from vertigo and may be ongoing rather than episodic 1
• Presyncope involves feeling like one might faint or pass out, which is NOT vertigo 3

Pathophysiologic Classification

The vestibular system's anatomy determines how vertigo manifests clinically:

• Peripheral vertigo results from dysfunction of the vestibule, semicircular canals, or vestibular nerve, and is usually characterized by acute rotational vertigo with loss of balance that worsens with head position changes 1, 4
• Central vertigo stems from lesions affecting central vestibular pathways in the brainstem, cerebellum, or their connections, and is often associated with focal neurological deficits 1, 4
• The vestibular end organs (vestibule and semicircular canals) are responsible for balance and equilibrium, with extensive brainstem connections to the cerebellum, extraocular nuclei, and spinal cord 1

Clinical Categorization by Temporal Pattern

The timing and triggers of vertigo episodes are more diagnostically valuable than the patient's subjective description of their symptoms 5:

• Brief episodic vertigo lasts seconds to minutes and is triggered by head movements, most commonly indicating benign paroxysmal positional vertigo (BPPV) 1, 5
• Acute persistent vertigo lasts days to weeks with constant symptoms, suggesting vestibular neuritis or potentially cerebellar infarction 1, 5
• Recurrent episodic vertigo with attacks lasting 20 minutes to 12 hours accompanied by hearing loss, tinnitus, and aural fullness defines Ménière's disease 1
• Chronic vestibular syndrome involves symptoms persisting for weeks to months, with differential diagnoses including anxiety disorders, medication side effects, and posttraumatic vertigo 5

Management Approach in Specific Populations

Older Adults with Vertigo

BPPV is the most common cause of vertigo in older adults (36.3% of cases), and 9% of elderly patients referred for geriatric evaluation have undiagnosed BPPV, with three-fourths having fallen within the prior 3 months 6:

• Dizziness increases fall risk 12-fold in elderly patients 5, 3
• Age-related physiological changes increase vulnerability, including reduced thirst, impaired sodium/water preservation, diminished baroreceptor response, and reduced heart rate response to orthostatic stress 3
• Polypharmacy is a major contributor to dizziness in the elderly, particularly with antihypertensives, sedatives, anticonvulsants, and psychotropic drugs 5, 3

Patients with Recent Head Injuries

• Posttraumatic vertigo can persist chronically, presenting with vertigo, disequilibrium, tinnitus, and headache due to peripheral or central vestibular damage 6
• Traumatic brain injury can be associated with BPPV in specific cases 6
• A trauma history is essential when evaluating chronic dizziness 5

Patients with Recent Infections

• Acute vestibular neuritis or labyrinthitis presents with acute persistent vertigo lasting days to weeks, often following viral illness 7
• Vestibular neuritis accounts for approximately 41% of peripheral vertigo cases 6
• Initial treatment includes vestibular suppressant medication followed by vestibular rehabilitation exercises 7

Critical Red Flags Requiring Urgent Evaluation

Up to 75-80% of patients with acute vestibular syndrome from posterior circulation stroke have no focal neurologic deficits, making stroke easy to miss 5, 6:

• Focal neurological deficits on examination 5
• Sudden unilateral hearing loss 5
• Inability to stand or walk 5
• Downbeating nystagmus or other central nystagmus patterns 5, 6
• New severe headache accompanying dizziness 5
• Failure to respond to appropriate vestibular treatments 5, 6

Pharmacologic Management

Meclizine hydrochloride is FDA-approved for the treatment of vertigo associated with diseases affecting the vestibular system in adults, with recommended dosage of 25 mg to 100 mg daily in divided doses 8:

• Common adverse reactions include drowsiness, dry mouth, headache, fatigue, and vomiting 8
• May cause drowsiness; patients should use caution when driving or operating machinery 8
• Should be prescribed with care to patients with asthma, glaucoma, or prostate enlargement due to potential anticholinergic action 8
• Coadministration with other CNS depressants, including alcohol, may result in increased CNS depression 8

Common Diagnostic Pitfalls to Avoid

• Never rely on the patient's description of "spinning" versus "lightheadedness" alone—instead focus on timing, triggers, and associated symptoms 5
• Assuming a normal neurologic exam excludes stroke is incorrect, as most posterior circulation stroke patients with acute vestibular syndrome have no focal deficits 5, 3
• CT head has extremely low diagnostic yield (<1%) for isolated dizziness and misses most posterior circulation infarcts; MRI with diffusion-weighted imaging is far superior (4% diagnostic yield) 5
• Vestibular migraine is extremely common (14% of vertigo cases) but often under-recognized, particularly in younger patients 6