Vertigo

1. Introduction

  • Definition: Vertigo is a symptom characterised by a false sensation of movement, typically a spinning or rotational feeling, often accompanied by nausea and imbalance.
  • Epidemiology: Vertigo is common, affecting approximately 20–30% of the population at some point in their lives. It is more prevalent in older adults and women.
  • Significance: While most cases are benign, vertigo can significantly impact quality of life and may indicate serious underlying neurological or cardiovascular conditions.

2. Causes and Risk Factors

  • Causes:
    • Peripheral Vertigo (inner ear dysfunction):
      • Benign paroxysmal positional vertigo (BPPV) – most common cause.
      • Meniere’s disease.
      • Vestibular neuritis or labyrinthitis.
    • Central Vertigo (brainstem or cerebellar dysfunction):
      • Stroke or transient ischaemic attack (TIA).
      • Multiple sclerosis.
      • Brain tumours.
    • Other Causes:
      • Migraine-associated vertigo.
      • Vestibular schwannoma (acoustic neuroma).
      • Head trauma or whiplash.
  • Risk Factors:
    • Older age, female gender.
    • History of ear infections or head injuries.
    • Cardiovascular risk factors (e.g., hypertension, diabetes, smoking).
    • Migraine or neurological disorders.

3. Pathophysiology

  • Vertigo occurs when there is a mismatch between sensory inputs from the vestibular system (inner ear), visual system, and proprioception.
  • Peripheral Vertigo: Dysfunction in the vestibular apparatus or vestibular nerve causes false signals to the brain, leading to the spinning sensation.
  • Central Vertigo: Lesions in the brainstem or cerebellum disrupt central processing of balance and spatial orientation.

4. Symptoms and Features

  • Peripheral Vertigo:
    • Sudden onset.
    • Severe spinning sensation, aggravated by head movement.
    • Associated with nausea, vomiting, and imbalance.
    • Hearing loss or tinnitus (in conditions like Meniere’s disease or labyrinthitis).
  • Central Vertigo:
    • Gradual onset, less intense spinning sensation.
    • Accompanied by neurological signs (e.g., diplopia, dysarthria, ataxia).
    • No hearing loss or tinnitus.

5. Complications

  • Increased risk of falls and related injuries.
  • Chronic vertigo can lead to anxiety, depression, or social isolation.
  • Delayed diagnosis of serious conditions like stroke or brain tumours can be life-threatening.

6. Diagnosis

  • Clinical Features: Detailed history (onset, duration, triggers) and physical examination.
  • Diagnostic Tests:
    • Dix-Hallpike manoeuvre: Confirms BPPV if it elicits nystagmus and vertigo.
    • Head impulse test: Assesses vestibulo-ocular reflex in peripheral vertigo.
    • Audiometry: Identifies hearing loss in Meniere’s disease or other inner ear conditions.
    • Imaging (MRI/CT): Evaluates central causes (e.g., stroke, tumour).
    • Blood tests: Rule out systemic causes like anaemia or thyroid dysfunction.

7. Management Overview

  • Goals: Relieve symptoms, treat underlying cause, and prevent complications.
  • Approach: Differentiation of peripheral vs central vertigo guides treatment.

8. Treatment Options with Cost (USD)

  • Symptomatic Relief:
    • Antihistamines (e.g., meclizine): ~$10–$20 per course.
    • Benzodiazepines (e.g., diazepam): ~$5–$20 per course.
    • Antiemetics (e.g., promethazine): ~$10–$30 per course.
  • Condition-Specific Treatments:
    • Canalith repositioning manoeuvres (e.g., Epley manoeuvre): Minimal cost in clinic settings.
    • Betahistine for Meniere’s disease: ~$20–$50 per month.

9. Advanced Treatment Options with Cost (USD)

  • Surgical Options:
    • Labyrinthectomy or vestibular nerve section for refractory Meniere’s disease: ~$10,000–$20,000.
    • Tumour excision (e.g., vestibular schwannoma): ~$50,000–$100,000.
  • Rehabilitation:
    • Vestibular rehabilitation therapy (VRT): ~$100–$500 per session.

10. Pharmacological Treatment

  • First-line: Antihistamines (meclizine or dimenhydrinate) for acute episodes.
  • Adjunctive: Antiemetics for nausea, benzodiazepines for severe anxiety or persistent symptoms.
  • Condition-Specific:
    • Betahistine for Meniere’s disease.
    • Corticosteroids for vestibular neuritis or acute inflammation.

11. Medication Tables

Table 1: Doses and Side Effects

DrugIndicationDoseCommon Side Effects
MeclizineSymptomatic vertigo relief25–50 mg orally every 6–8 hoursDrowsiness, dry mouth
DiazepamSevere vertigo or anxiety2–10 mg orally 2–4 times dailySedation, dizziness
BetahistineMeniere’s disease16–24 mg orally 2–3 times dailyHeadache, GI upset
PromethazineNausea and vomiting12.5–25 mg orally every 4–6 hoursDrowsiness, dry mouth
PrednisoloneVestibular neuritis40–60 mg daily for 7–10 daysGI upset, insomnia

Table 2: Brand Names and Approximate Costs (USD)

DrugBrand NamesApprox. Cost
MeclizineAntivert, Bonine$10–$20 per course
DiazepamValium$5–$20 per course
BetahistineSerc$20–$50 per month
PromethazinePhenergan$10–$30 per course
PrednisoloneDeltasone$10–$30 per course

12. Lifestyle Interventions

  • Avoid sudden head movements or changes in position to minimise symptoms.
  • Stay hydrated and avoid alcohol, caffeine, and smoking, which can exacerbate vertigo.
  • Engage in balance exercises or vestibular rehabilitation therapy to improve symptoms and prevent falls.
  • Use supportive devices (e.g., walking aids) if balance is significantly impaired.

13. Monitoring Parameters

  • Symptom resolution and frequency of vertigo episodes.
  • Monitor for adverse effects of medications, especially sedation or dependence on benzodiazepines.
  • Regular follow-up for chronic conditions like Meniere’s disease or central vertigo.

14. Patient Counseling Points

  • Educate on recognising triggers and avoiding situations that provoke vertigo.
  • Explain that most cases of peripheral vertigo are self-limiting and manageable with treatment.
  • Emphasise the importance of completing prescribed treatments and attending follow-up appointments for persistent or recurrent symptoms.
  • Provide reassurance for benign causes like BPPV, and highlight the importance of balance exercises to reduce recurrence.

15. Special Populations

  • In Elderly: Increased fall risk; avoid sedating medications where possible.
  • In Pregnancy: Use non-pharmacological measures first; avoid potentially teratogenic drugs.
  • In Neurological Conditions: Evaluate for central causes and manage accordingly.

16. Prevention

  • Manage cardiovascular risk factors (e.g., blood pressure, diabetes) to reduce the risk of stroke-related vertigo.
  • Use protective headgear during high-risk activities to prevent trauma-induced vertigo.
  • Maintain a healthy diet and lifestyle to minimise risks of vestibular disorders like Meniere’s disease.

17. FAQs

  1. What is vertigo?
    Answer: A sensation of spinning or dizziness, often caused by inner ear or neurological issues.
  2. What causes vertigo?
    Answer: Common causes include BPPV, vestibular neuritis, Meniere’s disease, and central nervous system disorders.
  3. How is vertigo treated?
    Answer: Treatment depends on the cause but includes medications, physical therapy, or procedures like the Epley manoeuvre.
  4. Is vertigo the same as dizziness?
    Answer: No, vertigo specifically refers to a spinning sensation, while dizziness can include lightheadedness or unsteadiness.
  5. Can vertigo go away on its own?
    Answer: Yes, many cases of peripheral vertigo like BPPV resolve spontaneously or with repositioning manoeuvres.
  6. What is BPPV?
    Answer: Benign paroxysmal positional vertigo, caused by dislodged crystals in the inner ear.
  7. How is Meniere’s disease managed?
    Answer: With low-sodium diets, diuretics, and medications like betahistine.
  8. Can stress cause vertigo?
    Answer: Stress can worsen vertigo symptoms, especially in migraine-associated vertigo.
  9. What is the Dix-Hallpike test?
    Answer: A clinical test to diagnose BPPV by triggering vertigo and observing nystagmus.
  10. Is vertigo dangerous?
    Answer: Peripheral vertigo is usually benign, but central vertigo may indicate serious conditions like stroke.
  11. How can I prevent vertigo?
    Answer: Avoid sudden head movements, maintain hydration, and manage underlying health conditions.
  12. What is vestibular rehabilitation therapy?
    Answer: A series of exercises to improve balance and reduce vertigo symptoms.
  13. Can vertigo be a sign of a stroke?
    Answer: Yes, especially if accompanied by neurological symptoms like weakness or vision changes.
  14. Can medications cause vertigo?
    Answer: Yes, certain drugs like antihypertensives or sedatives may contribute to dizziness.
  15. When should I see a doctor for vertigo?
    Answer: If symptoms are severe, recurrent, or accompanied by neurological signs.