if vertigo lasts < 1 minute after moving the head, this suggests BPV
most other causes result in vertigo lasting hours to days
continuous vertigo does not last months as the CNS adapts
exclude systemic vertigo such as due to:
hypotension
hypoglycaemia
vertigo is aggravated by coughing, sneezing, exertion, or loud noises (Tullio phenomenon) raises possibility of perilymphatic fistula
most other patients with acute vertigo with no obvious stroke (CVA) or red flags can be rapidly assessed in the ED and placed into one of the main causes of peripheral vertigo as outlined below.
such patients can then usually have treatment commenced and be admitted into an ED Short Stay Observation Unit (SSU) until they are safe to be discharged.
patients with red flags should be considered for brain CT scan ASAP.
red flags
features suggestive of a central cause such as:
sudden onset or severe headache (unless it is a usual migraine headache)
fever
decreased GCS
wide based ataxic gait or falling whilst walking rather than a careful gait with a lean to one side
attempt manoeuvre to displace calcifications within endolymph:
standard Epley manoeuvre
in step 1 & 2, head is hanging 30-40 degrees from the horizontal plane below the plane of a hard table surface where the patient rests during the test. This is to facilitate the relocation of particles toward the distal limb of the canal.
during step 3, the particles pass the zenith of the canal curvature to enter the common crux and progress away toward the vestibule where they enter during the 4th step.
modified Epley manoeuvre seems to be controversial and no longer recommended for home use as may subject patient to unnecessary further vertiginous episodes1)
modified Semont manoeuvre
not as effective as the modified Epley manoeuvre (see here)
prochlorperazine as for vestibular neuronitis
vestibular neuronitis
prednisolone 125 mg daily for 3 days, reducing by 25 mg every 3 days until taking 25 mg daily for 3 days, then 12.5 mg daily for 3 days (Aust. Therapeutic Guidelines 2008), plus,
prochlorperazine 12.5 mg IM (or 5-10mg orally, or 25mg rectally ), immediately, then oral or rectal dosing tds prn
Cochrane review 2006 - insufficient evidence of benefit
+/- betahistine (a vasodilator) 8-16mg bd
Cochrane review 2007 - insufficient evidence of benefit but no serious adverse outcomes and those that use it may find some benefit
migrainous vertigo
vertigo may occur as a typical aura prior to the onset of headache, as an isolated recurrent vestibular disorder (migraine equivalent), or rarely as a more chronic or fluctuating type of dizziness associated with motion sensitivity.
consider drugs used in the prophylaxis of migraine
recent hyperextension injury to neck, high-velocity chiropractic manipulation or neck pain
acute vertigo due to a vertebrobasilar stroke rarely occurs without other neurologic features of brainstem ischaemia such as diplopia, dysarthria, dysphagia, weakness, or numbness