Vertigo
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor-In-Chief: Cafer Zorkun, M.D., Ph.D. [2]
Causes
Diagnosis
Treatment
- Central disorders
- Treat underlying disease
- Vertebrobasilar ischemia
- Vertigo usually resolves on its own
- Risk factor modification to decrease recurrence
- +/- Revascularization or anticoagulation
- Migraine: adequate treatment of headache improves vertigo in 90%
- Multiple sclerosis (MS): Therapy for MS alleviates vertiginous symptoms as well
- Drugs: discontinue offending agents
- Peripheral disorders
- General management
- Physical therapy
- Beneficial in patients with permanent peripheral vestibular dysfunction
- Unknown benefit in patients with central disorders
- Vestibular rehabilitation
- Activity enables CNS adaptation to loss of vestibular input
- Visual compensation during head motion
- Balance shown to improve in randomized controlled trials of vestibular exercises
- Unclear if long-term benefits or if decreased fall risk
- Avoidance of inactivity
- Avoid deconditioning and loss of postural reflexes
Acute Pharmacotherapies
- Peripheral disorders
- Specific management
- BPPV
- Epley maneuver --> in a randomized controlled trial, symptoms resolved in 50% vs. 19% sham therapy by mean 10 days
- Meclizine (12.5-50 mg every 6 hours as often as necessary) or promethazine (25 mg every 6 hours as often as necessary) for severe symptoms
- Meniere’s disease: low-salt diet and diuretics to reduce endolymph production
- Peripheral disorders
- General management
- Pharmacologic therapy
- For acute episodes: Avoid long-term therapy if symptoms last > few days (will reduce CNS adaptation)
- Anticholinergics
- Scopolamine: Side effect urinary retention, dry mouth
- Antihistamines
- Meclizine, dimenhydrinate, diphenhydramine (anti-Ach effects)
- Meclizine is drug of choice in pregnancy. Side effect: sedation
- Phenothiazines
- prochlorperazine, promethazine (anti-Ach effects): More sedating, but also have antiemetic effects. Risk: extrapyramidal side effect (second-line)
- Benzodiazepines
- Diazepam, lorazepam, clonazepam (GABA-ergic effects): For patients with contraindications to anti-Ach prescription (benign prostatic hypertrophy)
Surgery and Device Based Therapy
- Perilymphatic fistula
- Bed rest, head elevation, avoidance of straining
- Surgical patch if no resolution after several weeks
- Acoustic neuroma: surgical therapy
References
Additional Resources
1. Hotson JR, Baloh RW. Acute vestibular syndrome. N Engl J Med 1998;339:680-5.
2. Dix MR, Hallpike CS. The pathology, symptomatology and diagnosis of certain common disorders of the vestibular system. Proc R Soc Med 1952;45:341-54.
3. Furman JM, Cass SP. Benign paroxysmal positional vertigo. N Engl J Med 1999;341:1590-6.
4. Disorders of equilibrium. In: Greenberg DA, Aminoff MJ, Simon RP. Clinical neurology. 5th ed. New York: McGraw-Hill, 2002:95-126.
5. Hasso AN, Drayer BP, Anderson RE, Braffman B, Davis PC, Deck MD, et al. Vertigo and hearing loss. American College of Radiology. ACR Appropriateness Criteria. Radiology 2000;215(suppl):471-8.
6. Hain TC, Uddin M. Pharmacological treatment of vertigo. CNS Drugs 2003;17:85-100.
7. Baloh RW. Vestibular neuritis. N Engl J Med 2003;348:1027-32.
8. Quigley EM, Hasler WL, Parkman HP. AGA technical review on nausea and vomiting. Gastroenterology 2001;120:263-86.
9. Fife TD. Episodic vertigo. In: Rakel RE, ed. Conn's Current therapy, 1999: latest approved methods of treatment for the practicing physician. 51st ed. Philadelphia: Saunders, 1999:923-30.
10. Baloh RW. Vertigo in older people. Curr Treat Options Neurol 2000;2:81-9.
11. Yardley L, Beech S, Zander L, Evans T, Weinman J. A randomized controlled trial of exercise therapy for dizziness and vertigo in primary care. Br J Gen Pract 1998;48:1136-40.
12. Cohen HS, Kimball KT. Increased independence and decreased vertigo after vestibular rehabilitation. Otolaryngol Head Neck Surg 2003;128:60-70.
13. Wrisley DM, Whitney SL, Furman JM. Vestibular rehabilitation outcomes in patients with a history of migraine. Otol Neurotol 2002;23:483-7.
14. Strupp M, Arbusow V, Maag KP, Gall C, Brandt T. Vestibular exercises improve central vestibulospinal compensation after vestibular neuritis. Neurology 1998;51:838-44.
15. Epley JM. The canalith repositioning procedure: for treatment of benign paroxysmal positional vertigo. Otolaryngol Head Neck Surg 1992;107:399-404.
16. Radtke A, Neuhauser H, von Brevern M, Lempert T. A modified Epley's procedure for self-treatment of benign paroxysmal positional vertigo. Neurology 1999;53:1358-60.
17. Humphriss RL, Baguley DM, Sparkes V, Peerman SE, Moffat DA. Contraindications to the Dix-Hallpike manoeuvre: a multidisciplinary review. Int J Audiol 2003;42:166-73.
18. Lynn S, Pool A, Rose D, Brey R, Suman V. Randomized trial of the canalith repositioning procedure. Otolaryngol Head Neck Surg 1995;113:712-20.
19. Froehling DA, Bowen JM, Mohr DN, Brey RH, Beatty CW, Wollan PC, et al. The canalith repositioning procedure for the treatment of benign paroxysmal positional vertigo: a randomized controlled trial. Mayo Clin Proc 2000;75:695-700.
20. Hilton M, Pinder D. The Epley (canalith repositioning) manoeuvre for benign paroxysmal positional vertigo. Cochrane Database Syst Rev 2004;(3):CD003162.
21. Nunez RA, Cass SP, Furman JM. Short- and long-term outcomes of canalith repositioning for benign paroxysmal positional vertigo. Otolaryngol Head Neck Surg 2000;122:647-52.
22. Sakaida M, Takeuchi K, Ishinaga H, Adachi M, Majima Y. Long-term outcome of benign paroxysmal positional vertigo. Neurology 2003;60:1532-4.
23. Van Deelen GW, Huizing EH. Use of a diuretic (Dyazide) in the treatment of Meniere's disease. A double-blind cross-over placebo-controlled study. ORL J Otorhinolaryngol Relat Spec 1986;48:287-92.
24. Santos PM, Hall RA, Snyder JM, Hughes LF, Dobie RA. Diuretic and diet effect on Meniere's disease evaluated by the 1985 Committee on Hearing and Equilibrium guidelines. Otolaryngol Head Neck Surg 1993;109:680-9.
25. James A, Thorp M. Meniere's disease. Clin Evid 2003;(9):565-73.
26. Blakley BW. Update on intratympanic gentamicin for Meniere's disease. Laryngoscope 2000;110(2 pt 1):236-40.
27. Levy EI, Hanel RA, Bendok BR, Boulos AS, Hartney ML, Guterman LR, et al. Staged stent-assisted angioplasty for symptomatic intracranial vertebrobasilar artery stenosis. J Neurosurg 2002;97:1294-301.
28. Norrving B, Magnusson M, Holtas S. Isolated acute vertigo in the elderly; vestibular or vascular disease? Acta Neurol Scand 1995;91:43-8.
29. Neuhauser H, Leopold M, von Brevern M, Arnold G, Lempert T. The interrelations of migraine, vertigo, and migrainous vertigo. Neurology 2001;56:436-41.
30. Johnson GD. Medical management of migraine-related dizziness and vertigo. Laryngoscope 1998;108(1 pt 2):1-28.
31. Reploeg MD, Goebel JA. Migraine-associated dizziness: patient characteristics and management options. Otol Neurotol 2002;23:364-71.
32. Bikhazi P, Jackson C, Ruckenstein MJ. Efficacy of antimigrainous therapy in the treatment of migraine-associated dizziness. Am J Otol 1997;18:350-4.
33. Jacob RG, Furman JM, Durrant JD, Turner SM. Panic, agoraphobia, and vestibular dysfunction. Am J Psychiatry 1996;153:503-12.
34. Staab JP, Ruckenstein MJ, Solomon D, Shepard NT. Serotonin reuptake inhibitors for dizziness with psychiatric symptoms. Arch Otolaryngol Head Neck Surg 2002;128:554-60.
35. Johansson M, Akerlund D, Larsen HC, Andersson G. Randomized controlled trial of vestibular rehabilitation combined with cognitive-behavioral therapy for dizziness in older people. Otolaryngol Head Neck Surg 2001;125:151-6.
36. Flake ZA, Scalley RD, Bailey AG. Practical selection of antiemetics. Am Fam Physician 2004;69:1169-74.
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