see also

• neurology
• examination of cranial nerves
• ataxia
• stroke (CVA)
• transient ischaemic attack (TIA)
• ED Mx of vertigo including BPV instructions

• see HINTS exam for vertigo and stroke

• horizontal or horizontorotary (esp. Meniere's which can last for hours)
• bilateral
• suppressed by visual fixation
• nystagmus induced by head position testing:
  • long latency 10-20sec
  • short-lasting
  • fatigable

• episode precipitated by turning head to side whilst lying in bed suggests BPV
• tinnitus
• conductive deafness
  • suggests wax against tympanic membrane or otitis media as the cause
• sensorineural deafness
  • suggests Meniere's disease, acoustic neuroma, ototoxins, suppurative labyrinthitis, perilymphatic fistula post-head injury
• absence of other cranial nerve pathology except impaired corneal reflex (acoustic neuroma)

• vertical or torsional nystagmus
• if horizontal then direction of fast phase alternates with gaze direction
• unilateral or bilateral
• may be enhanced by visual fixation
• nystagmus induced by head position testing:
  • short latency
  • sustained duration
  • non-fatigable

• wide based ataxic gait or truncal ataxia whilst sitting with arms on lap
• positive head impulse test
• positive skew test
• other neurology
  • vertebrobasilar infarct may cause either:
    • brainstem infarct ⇒ dysarthria, ataxia, facial numbness, hemiparesis, headache, diplopia
    • inf. cerebellar infarct ⇒ inability to walk, dysmetria, deafness
  • Wallenberg syndrome or lateral medullary syndrome due to occlusion of PICA
    • ⇒ ataxia, Horner's syndrome, loss of pain/temp. to ipsil. face & contralat. body; paralysis palate, pharynx, larynx.
  • multiple sclerosis (MS) ⇒ onset < 50yrs age; rotary/vert. nystagmus; internuclear ophthalmoplegia.
• other features:
  • subclavian steal - precipitate by exercising arm; check BP in each arm;
  • sudden onset severe headache
    • exclude cerebellar haemorrhage which is a surgical emergency
      • ataxia +/- gaze disturbance on looking to side of lesion; cannot walk
    • subarachnoid haemorrhage (SAH) - does not usually present with vertigo but may do.
    • vertebrobasilar migraine - usually PH migraine
  • meningism
    • suggests meningitis, subarachnoid haemorrhage (SAH) ⇒ CT scan +/- LP

• hypoglycaemia
• hypothyroidism ⇒ unsteadiness, truncal ataxia or generalised clumsiness
• hypotension