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.
- Peripheral Vertigo (inner ear dysfunction):
- 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
Drug | Indication | Dose | Common Side Effects |
---|---|---|---|
Meclizine | Symptomatic vertigo relief | 25–50 mg orally every 6–8 hours | Drowsiness, dry mouth |
Diazepam | Severe vertigo or anxiety | 2–10 mg orally 2–4 times daily | Sedation, dizziness |
Betahistine | Meniere’s disease | 16–24 mg orally 2–3 times daily | Headache, GI upset |
Promethazine | Nausea and vomiting | 12.5–25 mg orally every 4–6 hours | Drowsiness, dry mouth |
Prednisolone | Vestibular neuritis | 40–60 mg daily for 7–10 days | GI upset, insomnia |
Table 2: Brand Names and Approximate Costs (USD)
Drug | Brand Names | Approx. Cost |
---|---|---|
Meclizine | Antivert, Bonine | $10–$20 per course |
Diazepam | Valium | $5–$20 per course |
Betahistine | Serc | $20–$50 per month |
Promethazine | Phenergan | $10–$30 per course |
Prednisolone | Deltasone | $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
- What is vertigo?
Answer: A sensation of spinning or dizziness, often caused by inner ear or neurological issues. - What causes vertigo?
Answer: Common causes include BPPV, vestibular neuritis, Meniere’s disease, and central nervous system disorders. - How is vertigo treated?
Answer: Treatment depends on the cause but includes medications, physical therapy, or procedures like the Epley manoeuvre. - Is vertigo the same as dizziness?
Answer: No, vertigo specifically refers to a spinning sensation, while dizziness can include lightheadedness or unsteadiness. - Can vertigo go away on its own?
Answer: Yes, many cases of peripheral vertigo like BPPV resolve spontaneously or with repositioning manoeuvres. - What is BPPV?
Answer: Benign paroxysmal positional vertigo, caused by dislodged crystals in the inner ear. - How is Meniere’s disease managed?
Answer: With low-sodium diets, diuretics, and medications like betahistine. - Can stress cause vertigo?
Answer: Stress can worsen vertigo symptoms, especially in migraine-associated vertigo. - What is the Dix-Hallpike test?
Answer: A clinical test to diagnose BPPV by triggering vertigo and observing nystagmus. - Is vertigo dangerous?
Answer: Peripheral vertigo is usually benign, but central vertigo may indicate serious conditions like stroke. - How can I prevent vertigo?
Answer: Avoid sudden head movements, maintain hydration, and manage underlying health conditions. - What is vestibular rehabilitation therapy?
Answer: A series of exercises to improve balance and reduce vertigo symptoms. - Can vertigo be a sign of a stroke?
Answer: Yes, especially if accompanied by neurological symptoms like weakness or vision changes. - Can medications cause vertigo?
Answer: Yes, certain drugs like antihypertensives or sedatives may contribute to dizziness. - When should I see a doctor for vertigo?
Answer: If symptoms are severe, recurrent, or accompanied by neurological signs.