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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: ■■ benign paroxysmal positional vertigo ■■ vestibular neuritis or labyrinthitis ■■ Ménière’s disease ■■ migraine ■■ 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 © Manrex Pty Ltd (ABN: 63 074 388 088) t/as Webstercare - 2010 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: ■■ anticholinergics ■■ antihistamines ■■ benzodiazepines ■■ calcium channel blockers ■■ 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 © Manrex Pty Ltd (ABN: 63 074 388 088) t/as Webstercare - 2010 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: ■■ tricyclic antidepressant (TCA) ■■ beta-blocker ■■ calcium channel blocker ■■ anti-migraine medications Anti-migraine medications include: ■■ pizotifen (Sandomigran) 0.5 to 1 mg orally, at night, up to 3 mg daily ■■ propranolol (Inderal) 40 mg orally, 2 to 3 times daily, up to 320 mg daily ■■ verapamil (sustained-release) 160 or 180 mg orally, once daily, up to 320 or 360 mg daily ■■ ‘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.