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Chapter 170: Vertigo

Brian Goldman; Peter Johns

Content Update: Hints, Vertigo, and Nystagmus April 2020

Text change under BEDSIDE TESTING FOR BPPV: Note that although it is appropriate to perform the Dix-Hallpike test on patients with short episodes of dizziness brought on by head movement, and without spontaneous or gaze evoked nystagmus, such patients should not have the HINTS-Plus exam performed on them. The latter would produce erroneous results. The HINTS-Plus exam should be reserved for patients with ongoing constant vertigo and spontaneous or gaze evoked nystagmus. See Figure 170-2.

INTRODUCTION AND EPIDEMIOLOGY

Vertigo is defined as the sensation of self-motion when no motion is occurring. Vestibular disorders are conditions that affect the vestibular sensory organs in the inner ear or the cerebellum and brainstem and the connections between them.

Some patients have difficulty describing the sensation of vertigo. 1 Dizziness is a nonspecific word patients use to describe vertigo, but is also used by some patients to describe the symptoms of presyncope, imbalance, lightheadedness, and other sensations. Assess patients for nonvestibular causes of dizziness such as orthostatic hypotension, presyncope, and new medications such as antihypertensives.

Vertigo is a diagnostic challenge because it has many potential causes ( Table 170-1 ).

TABLE 170-1Peripheral and Central Causes of Vertigo
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TABLE 170-1 Peripheral and Central Causes of Vertigo
Peripheral Causes Relative Frequency of Presentation to the ED Key Points Clinical Course
Benign paroxysmal positional vertigo The most common cause of vertigo Less than 2-minute episodes of vertigo, initiated by head movement. Dix-Hallpike test shows vertical upward and rotatory nystagmus. Benign, particle repositioning maneuvers is first-line treatment. Medications rarely indicated.
Vestibular neuritis Common Hours/days of continuous, constant vertigo. Use HINTS plus exam if nystagmus present. Spontaneous improvement over days/weeks.
Labyrinthitis Less common Ear pain, tinnitus, and hearing loss onset 1 or more days before vertigo; otherwise similar to vestibular neuritis. A complication of otitis media. Serious if bacterial (rare).
Ménière’s disease Less common Recurrent episodes of vertigo, hearing loss, tinnitus, and ear fullness. Slowly progressive; can lead to profound hearing loss.
Perilymph fistula Rare Vertigo and hearing loss after head trauma or pressure changes to middle ear (flying/diving/nose blowing). Can benefit from surgical correction.
Superior canal dehiscence Rare Vertigo brought on by loud sounds, coughing, and straining. Surgery for severe cases.
Vestibular schwannoma Rare Slow onset of hearing loss, tinnitus, and less commonly, vertigo. Slowly growing; amenable to surgery if growing and symptomatic.
Central Causes
Vestibular migraine Most common central cause of vertigo, but much underdiagnosed. Recurrent attacks in patients with migraine, including episodes of isolated vertigo. About half the episodes have migrainous features. Most experts recommend treatment as per migraine headache.
Cerebellar/brainstem stroke Less common

Often presents with other neurologic signs or symptoms, but can present with symptoms similar to vestibular neuritis; use HINTS plus exam if nystagmus is present.

Hearing loss can occur at onset of stroke.

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