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ED Mx of vertigo and BPV


  • all vertigo is made worse by moving the head
    • 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
    • other cerebellar signs such as dysmetria
    • new focal neurology
        • negative head impulse test
        • horizontal nystagmus which alternates direction of fast phase depending upon gaze direction, or rotatory or vertical nystagmus
        • positive skew test
  • absence of at least one feature of peripheral causes such as:
    • deafness
    • tinnitus
    • vertigo lasting < 1 minute after head turn
    • a positive Hallpike test
  • neck pain, recent neck injury or high-velocity chiropractic manipulation raises possibility of vertebral artery dissection
  • higher risk patients:
    • elderly
    • diabetics
    • atypical symptoms

benign positional vertigo (BPV)

  • attempt manoeuvre to displace calcifications within endolymph:
    • standard Epley manoeuvre
    • 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

Meniere's disease

  • hydrochlorothiazide 25mg o daily (a diuretic)
    • 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

less common causes

      • 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
    • 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.
    • cerebellar haemorrhage which is a surgical emergency
      • ataxia +/- gaze disturbance on looking to side of lesion; cannot walk
  • perilymphatic fistula
  • acoustic nerve / cerebellopontine tumours
  • anticonvulsants toxicity may cause nystagmus +/- ataxia
  • multiple sclerosis (MS) ⇒ onset < 50yrs age; rotary/vert. nystagmus; internuclear ophthalmoplegia.
  • subarachnoid haemorrhage (SAH) - does not usually present with vertigo but may do
    • precipitate by exercising arm; check BP in each arm;
vertigo.txt · Last modified: 2019/04/30 16:18 (external edit)