see also:

• neurology
• ears, nose and throat surgery (ENT)
• anti-emetics
• central vs peripheral vertigo
  • see HINTS exam for vertigo and stroke
• Cutting-edge technology helps Eye and Ear patients - Melbourne Neuro-ENT with special interest in vertigo

• 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.

• 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
  • see also: central vs peripheral vertigo such as:
    • HINTS exam for vertigo and stroke
      • 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

• Vic DHS patient information sheet - vertigo / BPPV (pdf)
• 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.
    • EMRAPTV Episode 9: Hallpike and Epley maneuvers
    • Instructional diagrams to Rx benign positional vertigo
    • Claymation Epley Maneuver Video
  • 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

• 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

• endolymphatic hydrops including 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

• 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

• stroke or TIA:
  • vertebral artery dissection
    • 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
• raised intracranial pressure (ICP)
• seizures
• 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
• subclavian steal syndrome
  • precipitate by exercising arm; check BP in each arm;