Please note that the following is a general guideline only. For a full assessment, exclusion of any other underlying cause for your symptoms and an individualised treatment approach, you will need to be seen by a qualified specialist.
Vertigo Definition
Illusion of Rotation due to asymmetry in neural activity between the L and R vestibular systems (Halmagi)
Taking a History
First familiarize your self with the specific features of the above 6 causes of vertigo. These are discussed in the later part. What helps tell these apart are the differences in their onset, length of the symptoms and associated features.
History taking should be fairly directed ie “ do you feel light headed (not vertigo) or is the roof spinning around (true vertigo)”. How quickly does it come on, in a second or over long period. When it comes on does it last for hours/ or days with out stopping, or only a few seconds but keeps coming back over days when you move for example?
Following are the main aspects of history
1 Characterize “dizziness”-is it true vertigo not light headedness, True vertigo has a clear sense of motion.
If true vertigo determine if its central (central vertigo has neurological features) OR... Peripheral vertigo- know the specific features in history that characterizes each type of peripheral vertigo well (conditions discussed in the latter part)
2 Following are the important aspects of history which helps you differentiate
Onset/ predisposing factors
time course,
temporal pattern
3 Associated symptoms (think of DDs)
CNS symptoms-Central vertigo
Migraine features
Ear symptoms
Examination (the most important ones)
1 Nystagmus
Central features- Vertical nystagmus, direction changing
Peripheral features; horizontal or in BPPV rotatory
2 Head pulsion test-only positive in peripheral vertigo, -ve in central vertigo types
Get the patient to fixate on an object 2 m in front of him/ her
keep the head Flexed down by about 3o degrees
rapid flick-movement of the head to the right then repeat the same to the left
if the labyrinth is dysfunctional the eyes will not stay fixed on the object (ie eyes will move with the head and flick back)
see the following video
3 Dix Hallpike
If symptoms suggest BPPV do Dix Hallpike to confirm. see the following video
4- Romberg
Balance depends on a tripod
A the input from the eyes,
B the proprioceptors of feet and
C tone by the vestibular spinal tracts
stand pt with feed together/ or on cushions (proprioceptors are removed)
ask the pt to close the eyes- visual input is removed (ensure you are ready to catch them)
now the patient relies on their vestibular tone alone- if one side is affected they will sway to that side
note a cerebellar tumor will also have a positive Romberg, however with other central signs as follows
Look for central signs-
- Finger-nose test (dysmetria past-pointing, intention tremor)
- Ataxia (heel-toe)
- Head Titubation
- Dysarthria
- Otological
- Neurological
- Visual
- Autonomic
-Other cranial nerves affected
Vertigo Main Conditions
Vestibular Neuronitis
History
Onset: within minutes to hours) onset of severe,
Time course: 24 hrs or more prolonged rotatory vertigo, nausea, and postural imbalance.
No Hearing Loss (helps differentiate from labyrinthitis)
NO central features
Examination
Peripheral vestibular signs
Horizontal spontaneous nystagmus
Head pulsion test is positive (indicates it is NOT a central process)
Romberg positive to affected side
No other neurological findings
NO evidence of a central vestibular lesion- no other neurological findings
No hearing loss
Treatment
Supportive
Rx-Steroids
Labyrinthitis
History
Onset:Over hours
Time course: Goes on for a day or more-then slowly subsides
Other: patient is very unwell-vomiting severely, and severe vertigo
Sensory hearing loss in the affected ear (different from V neuronitis)
Examination
Peripheral signs i.e.
Nystagmus- horizontal
head pulsion positive
Romberg positive- falls to affected side
also may have a middle ear infection
Sensory neural hearing loss
Rx
short course of vestibular sup presents i.e. Diazepam and Stemetil/ steroids
Stop after about 2 days- allow compensation
if middle ear infection- antibiotics
Meniere's Disease
Over diagnosed (vestibular Migraine)
History
Onset:Vertigo only hours, pt may feel unwell for days
Has associated features ; Aural fullness, Rumbling tinnitus , Hearing loss and vertigo
Examination
Peripheral vestibular symptoms as above ie
Nystagmus- horizontal
head pulsion positive
Romberg positive- falls to affected side
BPPV
History
Very common
Onset-Short duration vertigo (seconds), with head movement, rolling in bed
Time course: Patient may call it days- as short duration episodes vertigo keeps over many days- need to specifically ask this
Movement brings it on i.e. turning in bed- wakes up with vertigo, or turning the head
Examination
Positive Dixhallpike test to the affected ear (see the above clip)
Treatment
Epley manoeuvre (not medical treatment)
Vestibular Migraine (very common)
Usually comes on over minutes to hours
Usually lasts over a day
Has other migraine features i.e.
Photophobia, Phonophobia
may have an aura
May have a headache not always
responds to migraine medications
can have other neurology i.e. ataxia, tinnitus, other cranial nerve/ neurology