Dizziness is a sensation that produces spatial disorientation.
Vertigo is a sensation of movement. It is usually perceived as a spinning sensation. Its cause is mainly neurological in origin, unlike presyncope – a feeling of light-headedness or faintness – whose cause is primarily cardiovascular.
Vertigo is often accompanied by nystagmus
Definition of terms
| Terms used | Definition |
|---|---|
| Vertigo | A sensation of movement. It can be rotational, linear, or tilting, such as “spinning”, “whirling”, or “turning”. It can be the movement of the patient or of their surroundings |
| Disequilibrium | Sensation of instability of body position while walking or standing. Described as being “off-balance.” |
| Oscillopsia | Blurred vision and inability to focus on objects with motion. For example, the individual cannot read a sign while walking. It is seen with loss of the vestibulo-ocular reflex in bilateral or central vestibular dysfunction. |
| Lightheadedness | Sense of impending faint or presyncope |
| Physiologic dizziness | Can be caused by motion sickness or height-related vertigo |
Types of dizziness
| Dizziness | Some causes |
|---|---|
| Physiologic dizziness | Motion sickness and height-related vertigo |
| Multi-sensory dizziness | Diabetes and aging, which result in partial loss of multiple sensory systems |
Characteristics of vertigo and some causes
| Characteristic | Examples |
|---|---|
| Single, prolonged episode of vertigo | Vestibular neuronitis, labyrinthine damage, lateral medullary (Wallenberg’s syndrome), and cerebellar infarction |
| Recurrent episodes of vertigo | Meniere’s disease, vertebrobasilar insufficiency, migraine, and perilymphatic fistula |
| Positional vertigo | Benign positional paroxysmal vertigo (BPPV) |
| Other causes of vertigo | Osteosclerosis, acoustic neuroma, cerebellopontine angle tumors, multiple sclerosis, Ramsay-Hunt syndrome, disequilibrium syndrome, anxiety, and drugs |
Classification of Vertigo
| Type | Description |
|---|---|
| Peripheral Vertigo | Involves vestibular organs and the vestibular nerve (first-order neurons) |
| Central Vertigo | Involves the brainstem and the central nervous System |
| Ocular Vertigo | Caused by a mismatch of information received from the eyes with the vestibular system and somatosensory system |
| Psychogenic Vertigo | Occurs in patients suffering from emotional tension and anxiety |
Central vs Peripheral Vertigo
| Peripheral vertigo | Central vertigo | |
|---|---|---|
| Intensity | Severe | Mild |
| Duration | Episodic | Lasts longer |
| Fatigability | Fatigues, adaptation | Does not fatigue |
| Associated symptoms | Nausea/vomiting, hearing loss, sweating, tinnitus | Weakness, numbness, falls, diplopia, dysarthria, dysphagia, ataxia (cerebellar infarct) |
| Eye closure | Symptoms are worse with eyes closed | Symptoms better with eyes closed |
| Nystagmus | Horizontal, may be unilateral, rotary | Vertical, bilateral |
| Ocular (gaze) fixation | Suppresses nystagmus (may not suppress during the acute phase) | No effect or enhances nystagmus |
| Causes | Benign Paroxysmal Positional Vertigo (BPPV, 50%), Vestibular neuritis, Labyrinthitis, Meniere’s disease, foreign body in ear canal, perilymphatic fistula, Aminoglycosides (vestibulotoxic), head trauma, congenital syphilis, acoustic neuroma, Cerebellopontine angle tumor, multiple sclerosis | Vertebrobasilar insufficiency, Wallenberg syndrome, Basilar migraine, Cerebellar infarction, Brainstem tumor, Epilepsy, Posterior circulation insufficiency, Ramsay-Hunt syndrome |
- Patient History
- Describe the dizziness: first, establish that the patient is experiencing vertigo and NOT pre-syncope: the patient may report that they or their surroundings feel like they are spinning or swaying while stationary in vertigo.
- Chronicity: how long has it been going on, and how long does it last? Episodic or constant? Acute or recurrent?
- Does the feeling change with any particular action? A change in position? Provoking factors – Head position, head injury, recent URTI, “pop” sensation or changes in ear pressure, headache
- Hearing loss? (most likely peripheral vertigo)
- Other symptoms include nausea, vomiting, and focal neurological defects such as diplopia, dysarthria, numbness, and weakness.
- Medications in current and past use: salicylates, aminoglycosides, glycopeptides (vancomycin), loop diuretics, antimalarials (chloroquine, quinine), cytotoxic drugs.
- History of trauma
- History of ear surgery
- How symptoms affect daily living (at home and occupational)
- Rule out stroke (Wallenberg’s syndrome, cerebellar infarct) and SOLs, particularly in older patients. Risk factors of stroke (age > 65 years, HTN, DM), hemisthesia, dysphagia, Cranial nerve palsy, symptoms of raised ICP: headache, vomiting, papilledema, diplopia, bradycardia, Hypertension, irregular breathing, altered mental status, papilledema on ocular exam. NB: It is important to do a Non-contrast CT in such patients
- Signs and symptoms of central vertigo
- Lasts longer (with the major exception of infarcts)
- Diplopia
- Dysarthria
- Dysphagia (especially brainstem lesions)
- Ataxia
- Vertical nystagmus (more notable with gaze fixation)
- No hearing loss or tinnitus
- Signs and symptoms of peripheral vertigo
- Tends to be episodic
- Tinnitus
- Hearing loss
- Severe nausea and vomiting
- Horizontal nystagmus (lessens with gaze fixation)
- Physical examination
- Vital signs for orthostatic hypotension
- Assess for nystagmus
- Romberg test
- The patient stands with feet at shoulder-width apart, and after a minute, is asked to close their eyes.
- Loss of balance → Positive Romberg test → vertigo
- Caloric stimulation test
- Tests the health of the vestibular nerve
- Normal ear (COWS- cold opposite, warm same): Cold water nystagmus, fast beat towards the opposite ear. Warm water nystagmus fast beat towards the same ear
- Vestibular nerve damage: Abnormal nystagmus
- Dix-Hallpike maneuver
- Gold standard test for diagnosing benign paroxysmal positional vertigo (BPPV)
- The patient is seated upright examination bed with their legs outstretched.
- Rotate the head 45 degrees in one direction (you must do both sides). Observe for nystagmus for about 30 seconds.
- Lower the patient down to a supine position with their head hanging over the bed (about 30 degrees below the horizontal plane)
- Observe for nystagmus for at least 30 seconds.
- A positive test is the presence of nystagmus.
- Contraindications include cervical instability, acute neck trauma, cervical disc prolapse, high-grade carotid stenosis, and vertebrobasilar disease.
- Other tests
- HINTS test (head impulse, nystagmus, and test for skew)
- Tandem walking
- Electronystagmography (ENG)/Videonystagmography (VNG) battery
- Investigations
- Complete blood count to look for infection and anaemia
- Elevated lymphocyte count in vestibular neuronitis
- Random blood sugar
- Hyperglycaemia is a systemic cause of vertigo
- Toxicology panel for any vestibulotoxic drugs
- Complete blood count to look for infection and anaemia