The Massachusetts General Hospital Handbook of Neurology

Authors: Flaherty, Alice W.; Rost, Natalia S.

Title: Massachusetts General Hospital Handbook of Neurology, The, 2nd Edition

Copyright 2007 Lippincott Williams & Wilkins

> Table of Contents > Adult Neurology > Vertigo

Vertigo

A. Dx

• 1. Dizziness : Ask if the feeling is of spinning, and in the feet vs. the head, may distinguish between vertigo (illusion of movement), lightheadedness (a feeling that one might faint), and poor balance all of which pts may call dizziness.

• 2. Other: Sudden onset, HA, tinnitus, hearing decrease, other cranial nerves, gait, trouble controlling limbs, length of episode, LOC, change in vision, N/V, worse when lay down/stand/stoop/turn neck, h/o trauma, anxiety, hypo- or hyperglycemia, or hypertension. Orthostatic BPs, bruits, hearing (q.v. p. 54), eye exam, tympanic membranes; consider Romberg, postural reflexes, hyperventilation 3 minutes, calorics (q.v. p. 222).

• 3. B r ny's test: On a stretcher, bring pt suddenly back from a seated position to supine with pt's head turned fully to the right and eyes open. Watch for nystagmus and vertigo for at least 1 min. Repeat with head to the left. Have a bucket handy in case of vomit.

B. DDx

R/o dizziness from cardiac problem, bleed, panic, hypoglycemia; poor balance from movement disorder, sensory deficits, or weakness.

• 1. Central vertigo:

  • a. H&P: Usually less sudden onset (or if sudden, with HA), less nausea, continuous sx indep. of posture, usually no hearing loss.

    • 1) Nystagmus: All varieties of nystagmus including vertical.

    • 2) Side of sx: Falling and nystagmus are to same side, that of the lesion (vs. peripheral nystagmus, which is to opposite side).

    • 3) B r ny's test: No latency to nystagmus, it lasts >30 sec, no habituation. Nystagmus can go in different directions from same head position.

  • b. Causes of central vertigo: Brainstem lesion, cerebellar lesion (especially AICA territory), acoustic schwannoma. DPH or barbiturates. Can see central vertigo in migraine or complex partial seizures. Multiple sclerosis may cause poor balance; rarely true vertigo. Vertebral dissection.

C. Peripheral (vestibular) vertigo

• 1. H&P: Often sudden, positional, with severe nausea, tinnitus, or decreased hearing.

  • a. Nystagmus: Horizontal or rotatory, in only one direction.

  • b. Side of sx: Sx are usually worse with bad ear facing down. Falling and dysmetria are to side of bad ear. Nystagmus (fast phase) is complicated.

D. Excitatory lesion

E.g., positional vertigo. Nystagmus (fast phase) is toward the affected ear.

• 1. Inhibitory lesion: E.g., vestibular neuronitis, otitis. Nystagmus away from the affected ear.

• 2. M ni re's: Unreliable.

  • a. B r ny's test: 2-20 sec latency to nystagmus; habituates in ~30 sec and on repeated testing.

• 3. Causes of peripheral vertigo:

  • a. Drug-induced: Alcohol, Abx, furosemide, quinidine, quinine, aspirin. DPH or barbiturates cause central vertigo, not peripheral.

  P.128

  • b. M ni re's dz: Usually with decreased hearing, ear fullness, tinnitus. Attacks of vertigo last minutes to hours, recur weeks to years. Try clonazepam 0.5 mg bid, meclizine 25 mg q6h, diuretics, or strict salt restriction.

  • c. Benign positional vertigo: From loose otoliths. Drugs work poorly. Better to move otoliths back out of posterior canal.

    • 1) Epley maneuver: See Figure 13.

      • a) Briskly lie pt on back with their head tilted 45 degrees towards the symptomatic side until vertigo stops.

      • b) Rotate their head the other way until vertigo stops.

      • c) Have pt roll body towards that side, carrying the head along until it points down 45 degrees, until vertigo stops.

      • d) Sit pt up, with head slightly down. Repeat two more times.

      Figure 13. The Epley maneuver in benign positional vertigo. (Courtesy of Timothy Hain, MD.)

    • 2) Brandt-Daroff desensitization exercises: If Epley fails. Do each step for 30 sec (or until vertigo stops). Sit on edge of bed. Lie on R side of body with head turned 45 degrees up toward ceiling. Sit up. Lie on L side with head turned 45 degrees up. Repeat this cycle five times per session, three sessions per day.

E. Vestibular neuronitis

Usually young, sudden onset, not recurrent, pos-tviral, normal hearing, and no tinnitus.

• a. Vestibular neuronitis: Usually young, sudden, not recurrent, postviral. No decreased hearing or tinnitus.

• b. Other infections: Chronic otitis media, herpes zoster oticus, syphilis (usually bilateral) .

P.129

F. Psychosomatic vertigo and dizziness

Fluoxetine may help both this and true peripheral vertigo. See Psychosomatic Neurology , p. 102.