Vertigo

Vertigo is a sensation of abnormal spinning movement of the patient or their surroundings. It is vital to establish whether the patient is describing true vertigo, pre-syncope or unsteadiness.

Presentations of dizziness can be secondary to chronic, benign disease (e.g. Meniere’s disease) through to life-threatening illness, e.g. atypical ACS or stroke. From an emergency perspective, it is important to differentiate between:

• peripheral vertigo, caused by lesions of the vestibular nerve and inner ear, e.g. benign paroxysmal positional vertigo (BPPV), labyrinthitis, Meniere’s disease or acoustic neuroma; and
• central vertigo, caused by lesions of the central nervous system, e.g. cerebellar or brainstem stroke, vertebro-basilar insufficiency, multiple sclerosis or drug toxicity.

History

Continuous or intermittent vertigo

• Positional, intermittent vertigo suggests BPPV.
• Continuous vertigo, also known as acute vestibular syndrome, suggests acute peripheral vestibulopathy, such as vestibular neuritis, labyrinthitis or cerebellar lesion.

Duration of onset

• Sudden onset suggests BPPV, stroke.
• Gradually progressive suggests tumour or demyelination.

Associated symptoms

• Hearing loss or tinnitus suggests vestibular neuritis, labyrinthitis or Meniere’s disease.
• Fever and ear pain suggests bacterial labyrinthitis.

Red flags

• Sudden headache, neck or facial pain, e.g. carotid or vertebral dissection, intracranial haemorrhage
• Focal neurological deficit
• Ataxia
• Persistent vomiting
• Syncope
• Visual loss
• Elderly patient
• Multiple risk factors for ischaemic stroke, e.g. atrial fibrillation, diabetes, hypertension, congestive cardiac failure or previous stroke

Examination

The physical examination should aim to identify cerebellar signs, which are tested as follows:

• Assess for scanning speech: patients with cerebellar lesions break complex phrases into individual syllables, e.g. ask the patient to repeat “the British Constitution”, “42 West Register Street”.
• Pronator drift: with eyes closed, arms outstretched and supinated, downward drift with pronation of one arm suggests contralateral corticospinal (upper motor neuron) weakness.
• Rebound test: as above, the patient is asked to keep their arm in position while the examiner pushes downwards, then suddenly releases. In cerebellar disease, there is loss of antagonist muscle response and the limb shoots above the original position.
• Finger-to-nose test, or heel-to-shin test: looking for past-pointing or intentional tremor.
• Rapid alternating movements, e.g. flipping one hand on the other or rapid foot tapping: slow or irregular movement, also known as dysdiadochokinesia, suggests a cerebellar lesion.
• Gait or truncal ataxia: cerebellar disease causes broad stance, staggering, and the patient may fall to the side of the lesion.

Presence of cerebellar signs should prompt further evaluation for posterior circulation stroke, preferably with MRI.

Head impulse, nystagmus and test of skew (HINTS) exam

Perform the HINTS exam in patients with continuous vertigo and otherwise normal neurological examination. This is because abnormalities in vestibulo-ocular reflex may be the only abnormal neurological finding in patients with cerebellar infarcts. The HINTS exam appears more sensitive for stroke than early MRI within the first 48 hours of symptoms when performed by trained professionals. It consists of 3 components: head impulse test, nystagmus and test of skew. If any portion indicates a central cause, further evaluation for stroke or central pathology is indicated, e.g. neurology referral with or without MRI.

Horizontal head impulse test

The head impulse test assesses the vestibulo-ocular reflex. With the patient sitting opposite the examiner and looking at the examiner’s nose, the patient’s head is rotated laterally 20–30 degrees, then rapidly returned to midline. The patient’s eyes are observed for ‘overshoot’ and saccadic adjustment, i.e. the eyes continue to travel in the direction of rotation then correct suddenly. This constitutes a positive test.

• An abnormal (positive) test as indicated by overshoot and corrective saccades is suggestive but not conclusive of peripheral vertigo.
• A normal (negative) test strongly indicates a central cause.

Watch this video from Peter Johns for an example of a positive head impulse test.

Nystagmus

Nystagmus is assessed by observing the patient’s gaze with head stationary. Initially looking straight ahead, then following the examiner’s finger as it is moved 30 degrees right, left, up and down. Nystagmus at extremes of gaze is normal and is referred to as physiological nystagmus. Pathological nystagmus is characterised by alternating slow eye movement in one direction (smooth pursuit) with a fast (saccadic) movement in the opposite direction. The direction of nystagmus is defined by the direction of the quick phase.

Nystagmus is typically present in central vertigo but often has atypical features, such as vertical, direction-changing, or non-fatigable nystagmus.

Typical characteristics of nystagmus

Test of skew

Also known as an alternate cover test, the patient fixates on a stationary target, e.g. the examiner’s nose. The examiner rapidly alternates a cover between the patient’s eyes to disrupt binocular fixation. On uncovering each eye, the examiner observes for a vertical corrective movement.

A vertical realignment indicates skew deviation, which is abnormal and suggests a central lesion, usually brainstem or cerebellar. This test is commonly used as part of the HINTS examination.

Conditions causing peripheral vertigo

Benign paroxysmal positional vertigo (BPPV)

• The most common cause of vertigo, with female predominance, and the greatest incidence in people aged 50–60 years.
• Occurs due to otoliths in the semicircular canal.
• Is usually sudden onset, with brief episodes of positional vertigo lasting approximately 30 seconds that resolve if no further motion.
• There is no associated hearing loss.
• Torsional (rotatory) and upbeating nystagmus fast phase predominantly towards affected ear, as seen on Dix-Hallpike manoeuvre.
• Positional manoeuvres, such as Epley, may result in rapid recovery. Refer to video Epley Maneuver to Treat BPPV Vertigo from Fauquier ENT for the technique.
• Treatment is otherwise supportive with anti-emetics.
• Refer to the benign paroxysmal positional vertigo patient fact sheet.

Vestibular neuritis

• Likely caused by virus (HSV or zoster) and may follow flu-like illness.
• Onset is over hours, resolving over days.
• Vertigo occurs with head stationary.
• Horizontal nystagmus occurs at rest.
• Treat with antiemetics and/or antihistamines.
• Corticosteroids may offer some benefit but evidence is limited. Consider case by case.

Labyrinthitis

• May be viral or bacterial (from otitis media).
• Similar to vestibular neuritis with tinnitus or hearing loss.
• Toxic-appearing patients may require admission for IV antibiotics.

Meniere’s disease

• Often occurs in middle age due to decreased endolymph resorption.
• Causes episodes of vertigo lasting between 30 mins and 24 hours.
• Horizontal, jerky nystagmus associated with nausea, vomiting and sweating.
• Low-pitched unilateral tinnitus. Management involves restricting salt and caffeine intake, thiazide diuretics.

Resources

Emergency procedures: Vertigo
A range of video resources on clinical assessment of vertigo, including HINTS plus (log-in required)
Source: Emergency Procedures

Corticosteroids for the treatment of idiopathic acute vestibular dysfunction (vestibular neuritis)
A review of 4 randomised controlled trials with idiopathic acute vestibular disfunction.
Source: Cochrane Database of Systematic Reviews 

HINTS to diagnose stroke in the acute vestibular syndrome
This study found the 3-step bedside oculomotor examination more sensitive than early MRI diffusion-weighted imaging.
Source: Stroke

GRACE-3: Acute dizziness and vertigo in the emergency department
Evidence-based recommendations for diagnosing and tresating patients with acute dizziness.
Source: Society for Academic Emergency Medicine