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AUGUST 2010
VERTIGO
D
izziness is a common complaint, affecting 20-30%
of people in the general population.
Vertigo is just one type of dizziness and is often described
as rotary or spinning symptoms. It accounts for around onethird of all cases of dizziness and over half of the cases in
the older population.
Vertigo is usually due to a problem with the inner ear. It is
not the same as feeling off balance or about to faint.
It is important to have the resident describe the feeling of
dizziness to determine the correct diagnosis and treatment.
Causes
True vertigo is often caused by inner ear diseases whereas
other symptoms of dizziness, for example, light headedness
(presyncope), postural unsteadiness or imbalance
(disequilibrium), and generalised weakness can be caused
by central nervous system, cardiovascular, or systemic
diseases. Vertigo and motion sickness are not the same.
Peripheral vertigo
Peripheral vertigo is due to a disease originating from the
inner ear. It is often abrupt in onset, and can be associated
with nausea, vomiting, hearing loss, tinnitus (ringing,
buzzing or swishing in the ear or head), or ear pressure.
Types of vertigo caused by peripheral vestibular (inner ear) disorders include:
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benign paroxysmal positional vertigo
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vestibular neuritis or labyrinthitis
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Ménière’s disease
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migraine
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anxiety disorders
Benign paroxysmal positional vertigo (BPPV) is a balance
disorder that results in the sudden onset of dizziness,
spinning, or vertigo when moving the head. Episodes of
BPPV usually last less than one minute.
Vestibular neuritis occurs due to inflammation of the
vestibular nerve in the inner ear. In this condition, patients
usually describe a spinning feeling in a horizontal direction
that usually lasts more than 24 hours. Rapid head movements
and activities such as sitting up or turning over in bed may
cause increased vertigo.
Hearing loss may occur with labyrinthitis and almost always
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nausea or vomiting is experienced. Ataxia (wobbliness)
and nystagmus (rapid rhythmic repetitious involuntary eye
movements) may also be present.
Ménière’s disease is a recurrent vertigo accompanied by
ringing in the ears (tinnitus) and deafness. Episodes usually
last for hours and are accompanied by auditory symptoms.
Symptoms of Ménière’s disease include vertigo, dizziness,
nausea, vomiting, loss of hearing (in the affected ear), a
sense of fullness in one ear, and abnormal eye movements.
Vertigo with migraine may last minutes, hours or even days.
Central vertigo
Central vertigo is due to disease originating from the
central nervous system. It often produces other neurological
symptoms and is usually of gradual onset. The symptoms of
central vertigo are less intense than those associated with
peripheral vertigo.
Vertigo lasting more than a few days is suggestive of a
more serious condition such as stroke or transient ischaemic
attacks (TIAs) and should be referred to the resident’s
medical practitioner.
Vertigo is commonly associated with anxiety disorders such
as panic disorder and generalised anxiety disorder (GAD),
and less frequently depression. Other conditions such as
Parkinson’s disease should also be considered.
Medications
Medications such as aminoglycosides (gentamicin),
frusemide, antidepressants, alcohol and antipsychotics can
all cause vertigo.
Symptoms
A good question to ask to determine if dizziness is caused
by vertigo is:
‘When you have dizzy spells, do you feel light-headed or do
you see the world spinning around you?’
It can also be useful to ask the patient whether the problem
is, in their legs or in their head, or whether the sensations
are as if they are about to faint (presyncope) as opposed to
“being on a merry-go-round”.
It is important to determine the duration of episodes and
whether auditory symptoms are present to determine the
Vertigo, continued
correct diagnosis.
Treatment
Treatment of vertigo depends on the cause. Medications are
most useful for treating acute vertigo that lasts a few hours
to several days.
Classes of medications useful in the treatment of vertigo
include:
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anticholinergics
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antihistamines
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benzodiazepines
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calcium channel blockers
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dopamine receptor antagonists
In small doses, benzodiazepines are useful in the management
of vertigo. The benefits need to be assessed against the
risk of habituation and tolerance, impaired memory and
increased risk of falling. Long-acting benzodiazepines are
usually not helpful for the relief of vertigo.
Benign paroxysmal positional vertigo
Benign paroxysmal positional vertigo is managed by a
repositioning procedure called the Epley manoeuvre. It is
safe and effective and has a success rate of at least 50%
with a single treatment and close to 100% with repeated
manoeuvres.
Medications are not particularly useful in the management
of this condition. Antiemetics (e.g. Maxolon or Motilium)
can be helpful in people who experience nausea following
the vertigo spell.
Vestibular neuritis
Prednisone or prednisolone (125mg daily and tapered over
18 days) is effective for the treatment of vestibular neuritis.
Although the condition is often caused by a virus, the
addition of antiviral therapy provides no extra benefit.
Symptomatic treatment includes the use of prochlorperazine
(Stemetil), although long-term use is not recommended and
should be avoided. During the acute phase, patients benefit
from bed rest.
Ménière’s disease
Ménière’s disease treatment usually commences with a
low-salt diet and administration of a diuretic, for example,
hydrochlorothiazide 25mg daily. Combination diuretics
such as Hydrene (hydrochlorothazide/triamterene) are also
used. Less than 1 to 2g of salt per day is recommended.
These treatments can also prevent flare-ups and reduce the
frequency of attacks.
Vestibular suppressants such as anticholinergics and
benzodiazepines are also used.
Betahistine (Serc) is a vasodilator that works by increasing
the blood supply to the inner ear and is also an antihistamine.
It is taken in doses of 8 to 16mg twice daily. It is not certain
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whether Serc has any benefit in the treatment of Ménière’s
disease.
Ginkgo biloba is promoted for the treatment of tinnitus
although there is no evidence of any effect.
Migraine
Migraine with vertigo generally improves with dietary
changes such as a reduction or elimination of aspartame,
chocolate, caffeine and alcohol.
Medications that are used for migraine prophylaxis are also
often useful in the management of migrainous vertigo:
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tricyclic antidepressant (TCA)
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beta-blocker
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calcium channel blocker
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anti-migraine medications
Anti-migraine medications include:
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pizotifen (Sandomigran) 0.5 to 1 mg orally, at night, up to 3 mg daily
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propranolol (Inderal) 40 mg orally, 2 to 3 times daily, up to 320 mg daily
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verapamil (sustained-release) 160 or 180 mg orally, once daily, up to 320 or 360 mg daily
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‘triptans’ e.g. sumatriptan
Antiemetics such as metoclopramide (Maxolon, Motilium)
may be needed for nausea or vomiting.
Anxiety
Vertigo with anxiety usually responds to a SSRI
antidepressant. Non-drug treatments such as cognitive
behavioural therapy (CBT) may also be helpful.
Summary
Vertigo is a common form of dizziness and may be due
to a number of underlying conditions. Vertigo needs
to be distinguished from the three other categories of
dizziness: presyncope, disequilibrium of the elderly,
and “lightheadedness”. Treatment of vertigo is mainly
symptomatic.
References
American Family Physician 2005;71:1115-22.
Australian Family Physician 2008;37:341-7.
Australian Family Physician 2008;37:409-13.
Therapeutic Guidelines.