VERTIGO AYESHA SHAIKH PGY2 EMORY FAMILY MEDICINE 09.17.2008 CASE 31,female doctor, otherwise healthy, post partum week 5. First episode, sudden feeling of room spinning, while entering patient data in computer, during Family Medicine Clinic… One fine day last year same time! DIZZINESS • Vertigo • Lightheadedness • Pre syncope • Dys-equilibrium VERTIGO FALSE SENSE OF MOTION, usually rotational. 2 TYPES 1- CENTERAL VESTIBULAR CAUSES (Brain stem or cerebellum) 2- PERIPHERAL VESTIBULAR CAUSES ( Labyrinth or vestibular nerve) CAUSES OF VERTIGO CENTRAL PERIPHERAL Cerebellopontine Acute labrynthitis angle tumor Vestibular neuritis BPPV Cerebrovascular Cholestotoma disease Menier’s disease Migraine Ostosclerosis Multiple sclerosis Perilymphatic fistula Causes.. Drugs Alcohol Aminoglycosides Anticonvulsants Antidepressants Antihypertensives Barbiturates Cocaine ( Slowly progressive Unilateral/Bilateral) History Timings Duration Provoking, aggreviating factors Associated symptoms Risk factors for Cardiovascular disease Q: When you have dizzy spells , do you feel lightheaded or do you see the world spin around you? Q: Duration of Vertigo and associated symptoms? ( differentiate peripheral vs central causes) Typical Duration of Symptoms for Different Causes of Vertigo Duration of episode Suggested diagnosis A few seconds Peripheral cause: unilateral loss of vestibular function; late stages of acute vestibular neuronitis; late stages of Ménière's disease Several seconds to a few minutes Benign paroxysmal positional vertigo; perilymphatic fistula Several minutes to one hour Posterior transient ischemic attack; perilymphatic fistula Hours Ménière's disease; perilymphatic fistula from trauma or surgery; migraine; acoustic neuroma Days Early acute vestibular neuronitis*; stroke; migraine; multiple sclerosis Weeks Psychogenic (constant vertigo lasting weeks without improvement) *-Vertigo with early acute vestibular neuritis can last as briefly as two days or as long as one week or more. Information from references 3, 6, and 12. Provoking Factors for Different Causes of Vertigo Provoking factor Suggested diagnosis •Changes in head position Acute labyrinthitis; benign positional paroxysmal vertigo; cerebellopontine angle tumor; multiple sclerosis; perilymphatic fistula •Spontaneous episodes Acute vestibular neuronitis; cerebrovascular disease (stroke or transient ischemic attack); (i.e., no consistent Ménière's disease; migraine; multiple sclerosis •provoking factors) •Recent upper respiratory viral illness Acute vestibular neuronitis •Stress Psychiatric or psychological causes; migraine •Immunosuppression (e.g., immunosuppressive Herpes zoster oticus medications, advanced age , stress) •Changes in ear pressure, Perilymphatic fistula head trauma, excessive straining, loud noises •Information from references 1, 3, 5, 12, and 13. Associated Symptoms for Different Causes of Vertigo Symptom Suggested diagnosis Aural fullness Acoustic neuroma; Ménière's disease Ear or mastoid pain Acoustic neuroma; acute middle ear disease (e.g., otitis media, herpes zoster oticus) Facial weakness Acoustic neuroma; herpes zoster oticus Focal neurologic Cerebellopontine angle tumor; cerebrovascular disease; findings) multiple sclerosis (especially findings not explained by single neurologic lesion Headache Acoustic neuroma; migraine Hearing loss Ménière's disease; perilymphatic fistula; acoustic neuroma; cholesteatoma; otosclerosis; transient ischemic attack or stroke involving anterior inferior cerebellar artery,herpes zoster oticus Imbalance Acute vestibular neuronitis (usually moderate); cerebellopontine angle tumor (usually severe) Nystagmus Peripheral or central vertigo Phonophobia, photophobia Migraine Tinnitus Acute labyrinthitis; acoustic neuroma; Ménière's disease Information from references 1, 6, and 12 through 14. Table 5 Causes of Vertigo Associated with Hearing Loss Diagnosis Characteristics of hearing loss Acoustic neuroma Progressive, unilateral, sensorineural Cholesteatoma Progressive, unilateral, conductive Herpes zoster oticus (i.e., Ramsay Hun syndrome) Subacute to acute onset, unilateral Ménière's diseases Sensorineural, initially fluctuating, initially affecting lower frequencies; later in course: progressive, affecting higher frequencies Otosclerosis Progressive, conductive Perilymphatic fistula Progressive, unilateral Transient ischemic attack or stroke involving anterior inferior cerebellar artery or internal auditory artery Sudden onset, unilateral Information from references 9, 12, and 13. Distinguishing Characteristics of Peripheral vs. Central Causes of Vertigo Feature Peripheral vertigo Central vertigo Nystagmus Combined horizontal and torsional; Purely vertical, horizontal, or torsional inhibited by fixation of eyes onto object; ; not inhibited by fixation of eyes onto object; fades after a few days; does not change may last weeks to months direction with gaze to either side ; may change direction with gaze Imbalance Mild to moderate; able to walk Severe; unable to stand still or walk Nausea May be severe Varies , vomiting Hearing loss, tinnitus Common Rare Nonauditory Rare Common neurologic symptoms Latency following provocative diagnostic Longer (up to 20 seconds) Shorter (up to 5 seconds) maneuver) Information from references 14 and 15. Physical Exam Special attention to head and neck Cardiovascular and neurologic symptoms Provocative diagnostic tests Physical Exam Vertical nystagmus is 80% sensitive for central lesions. Horizontal nystagmus for peripheral lesions. Rhomberg sign : sensitivity 19 % only for peripheral causes. Dix-Hallpike maneuver PPV 83%, NPV 52 %. Clues to Distinguish Between Peripheral and Central Vertigo Clues Peripheral vertigo Central vertigo Findings on Latency of symptoms None Dix-Hallpike and nystagmus 2 to 40 seconds maneuver Severity of vertigo Severe Mild Duration of nystagmus Usually< 1 minute Usually>1 minute Fatigability* Yes No Habituation† Yes No Other findings Postural instability Able to walk; Falls while walking; unidirectional instability severe instability Hearing loss or tinnitus Can be present Usually absent Other neurologic Symptoms Absent Usually present *-Response remits spontaneously as position is maintained. †-Attenuation of response as position repeatedly is assumed. Information from references 3 and 4. Diagnosis History Physical Exam: Orthostatic vital signs, and Otoscopic examination, Neurologic Exam: Dix-Hallpike Maneuver ( central vs Peripheral) Complete Audiometric Testing for suspected Menier’s disease No LAB testing! Brain imaging : MRI with contrast for acute vertigo and Sensorineural hearing loss, MRA for vertebrobasilar circulation Disorder Duration Auditory Prevalence Peripheral or central symptoms vertigo Benign paroxysmal Seconds No Common Peripheral positional vertigo Perilymphatic fistula (head Seconds Yes Uncommon Peripheral trauma, barotrauma) Vascular Ischemia,TIA Seconds to hours Usualy not Uncommon Central or peripheral Meniere’s disease Hours yes common peripheral Syphillis Hours yes Uncommon central Vertiginous migraine Hours No Common Central Labyrinthitis Days Yes common peripheral Vascular Ischemia: Stroke Days Usually not Uncommon Central or peripheral Vestibular neuronitis Days No Common Peripheral Anxiety disorder Variable Usually not Common Unspecified Acoustic neuroma months yes Uncommon Peripheral Multiple sclerosis Months no uncommon central Vestibular ototoxicity months yes uncommon peripheral General Treatment Principles Medication for Acute Vertigo that lasts for few hours to several days Medications have various combinations of acetylecholine, dopamineand histamine receptor antagonism. Benzodiazepines enhance GABA action ( GABA is inhibitory neurotransmitter in vestibular system) Strength of Recommendation Key clinical recommendation •The canalith repositioning procedure (Epley maneuver) is recommended in patients with benign paroxysmal positional vertigo. A •The modified Epley maneuver also is effective in patients with benign paroxysmal positional vertigo.B •Vestibular suppressant medication is recommended for symptom relief in patients with acute vestibular neuronitis. C •Vestibular exercises are recommended for more rapid and complete vestibular compensation in patients with acute vestibular neuronitis. B •Treatment with a low-salt diet and diuretics is recommended for patients with Ménière's disease and vertigo.B •Effective treatments for vertiginous migraine include migraine prophylaxis (e.g., tricyclic antidepressants, beta blockers, calcium channel blockers), migraine-abortive medications (e.g., sumatriptan [Imitrex]), and vestibular rehabilitation exercises B •Selective serotonin reuptake inhibitors can relieve vertigo in patients with anxiety disorders. Because of side effects, slow titration is recommended.B A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, opinion, or case series. See page 1046 for more information. Medications Meclizine* (Antivert) 12.5 to 50 mg orally every 4 to 8 hour Dimenhydrinate* (Dramamine) 25 to 100 mg orally, IM, or IV every 4 to 8 hours Diazepam (Valium) 2 to 10 mg orally or IV every 4 to 8 hours Lorazepam (Ativan) 0.5 to 2 mg orally, IM, or IV every 4 to 8 hours Metoclopramide (Reglan) 5 to 10 mg orally every 6 hours 5 to 10 mg by slow IV every 6 hours Prochlorperazine (Compazine) 5 to 10 mg orally or IM every 6 to 8 hours 25 mg rectally every 12 hours 5 to 10 mg by slow IV over 2 minutes Promethazine (Phenergan) 12.5 to 25 mg orally, IM, or rectally every 4 to 12 hours Vestibular Rehabilitation Exercises These exercises train the brain to use alternative visual and proprioceptive clues to maintain balance and gait. Improve postural control during the first month after acute unilateral vestibular lesions resulting from vestibular neuronitis. Treatment of Specific Disorders 1- BPPV (Usually posterior canal Calcium Debris) MEDS..? Head Rotation Maneuvers Eply Maneuver Contraindication: Severe carotid stenosis, unstable heart disease, severe neck disease Success rate: 80 % after one treatment, 100% with repeated treatments. Recurrence rates: 15% /year, 20% @ 20 months, and 37% @ 60 months. Treatment of specific Disorders 2- Vestibular Neuronitis ( Acute Prolonged Vertigo) Symptom relief using vestibular suppressant medications, followed by vestibular exercises. Vestibular compensations occurs more rapidly and more completely if the patient begins twice-daily vestibular rehabilitation exercises soon after symptom control with medications. Treatment of specific disorders 3-Menier’s Disease (Distension of Endolymphatic compartment due to impaired endolymphatic filtration and excretion) Low salt diet ( < 1-2 gm/day) Diuretics ( combo HCTZ and Triamterene) Surgery in rare cases - ablation of vestibular hair cells) 4- Vascular Ischemia (Sudden onset of vertigo with additional symptoms eg diplopia, ataxia, dysphagia, dysarthria) TIA /Stroke: BP control, Cholesterol Lowering , smoking cessation, inhibition of platelet function, anticoagulation Vestibualr suppressant medications plus minimal head maneuver on first day, then initiate rehabilitation Vestibular stents for symptomatic critical vertebral artery stenosis. 6-Migraine Headaches Treat Migraine! Reduce or eliminate Aspartame, chocolate, caffeine and alcohol, Lifestyle changes, Vestibular rehabilitation exercises. Meds: BDZ, TCA, BB, SSRI, CCB, Antiemetics. 7- Psychiatric Disorders ( Anxiety , Panic disorders more common than depression; Hyperventilation is the cause.) Vesibular supressants and Benzodiazepines- transient to inadequate relief. SSRI show better relief. Cognitive behaviour therapy may be helpful. Physiologic Vertigo Motion sickness: incongruence in the sensory input from the vestibular, visual, and somatosensory systems.Visual system does not sense the movement. Bring systems back in congruence! Eg watch horizon when on a boat.also scopolamine patch behind ear 4 hours before boating. Disorder Duration Auditory Prevalence Peripheral or central symptoms vertigo Benign paroxysmal Seconds No Common Peripheral positional vertigo Perilymphatic fistula (head Seconds Yes Uncommon Peripheral trauma, barotrauma) Vascular Ischemia,TIA Seconds to hours Usualy not Uncommon Central or peripheral Meniere’s disease Hours yes Common Peripheral Syphillis Hours yes Uncommon central Vertiginous migraine Hours No Common Central Labyrinthitis Days Yes Common Peripheral Vascular Ischemia: Stroke Days Usually not Uncommon Central or peripheral Vestibular neuronitis Days No Common Peripheral Anxiety disorder Variable Usually not Common Unspecified Acoustic neuroma months yes Uncommon Peripheral Multiple sclerosis Months no uncommon central Vestibular ototoxicity months yes uncommon peripheral Dix-Hallpike Maneuver Epley Maneuver Internet resources for patient education http://www.youtube.com/watch?v=hhi nu_oU_hM http://www.youtube.com/watch?v=NQ r7MKJBAJY http://www.youtube.com/watch?v=eO uzUi5ckrk THANKS ! References Labuguen R. Initial Evaluation of Vertigo. American Family Physician. January 15, 2006. Swartz R, Longwell P. Treatment of Vertigo. American Family Physician. March 15, 2005.