Definition/Key Clinical Features

• Brief episodes of vertigo and nystagmus provoked by head movement
• Episodes usually no longer than 1 min, recur with head position changes
• Torsional or horizontal eye movement abnormalities common
• Example: intorsion and depression of one eye, extorsion and depression of the other

• Severe rotational vertigo often accompanied by nausea and vomiting
• Often preceded by URI
• Symptoms often abate by 72 hr but may persist up to 6 wk
• Hearing often preserved, which differentiates this condition from labyrinthitis

• Attacks of vertigo with hearing loss, tinnitus, and ear fullness
• Attacks last 2–24 hr
• Gradual hearing loss typical: low-frequency early, high-frequency later
• Sudden falls common
• Attacks may be triggered by loud noise

• Patient-reported balance disturbance (vertigo, unsteadiness) with normal balance on testing
• Triggered by specific locations or situations
• Commonly follows stressful event or illness

• Ischemia in brain stem, cerebellum, or labyrinth from narrowing of basilar artery branches
• Potentially life-threatening
• Dizziness in 2/3 of patients at some point
• Attacks last minutes
• Wide variety of neurologic changes but hearing usually spared

• Vertigo as toxic effect of drug use, often with other drug-specific features
• Alcohol: ataxia, speech changes, postural instability, nystagmus
• Tranquilizers, antidepressants: orthostatic hypotension
• Anticonvulsants: cerebellar dysfunction
• Antibiotics (especially gentamicin); aspirin (high-dose); chemotherapeutic agents (e.g., cisplatin): gait instability

• Attacks of vertigo and nystagmus in patients with migraine
• Vertigo and nystagmus last for minutes
• May occur independently of headache
• History of carsickness in childhood
• Second most common neurologic manifestation of migraine (after visual distortions)

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Differential Diagnosis

• Extensive; dizziness can be secondary to many systemic and intracranial disorders
• Stroke, transient ischemic attack, seizure disorder
• HIV infection, Lyme disease, syphilis
• SLE, multiple sclerosis, giant cell arteritis, sarcoidosis
• Neoplasia
• Otosclerosis, labyrinthitis
• Thyroid disease

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Best Tests

• Detailed history of episodes, patient's subjective experience, hearing loss, familial occurrences
• Examination for nystagmus, balance disturbance
• Maneuvers to provoke nystagmus, such as Dix-Hallpike
• MRI, MRA if tumor or vascular insufficiency is suspected

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Best Therapy

Benign Paroxysmal Positioning Vertigo

• Particle repositioning maneuvers
• Drug therapy inappropriate

Vestibular Neuritis

• Symptomatic: meclizine, diazepam, oxazepam, or clonazepam in first 72 hr
• After 72 hr, drugs may provide relief but may prolong recovery and are sedating
• Caffeine or methylphenidate to reduce sedation
• Usually self-limited; if prolonged, may require vestibular nerve section or chemical treatment

Meniere Disease

• Diuretics, salt restriction, weight loss
• Vestibular suppressants
• Meclizine
• Diazepam
• Oxazepam
• Clonazepam
• Antiemetics for nausea
• Endolymphatic shunting used for refractory cases

Phobic Postural Vertigo

• Vestibular rehabilitation with counseling and exercise
• Diazepam, oxazepam, or clonazepam as adjunct
• Management of depression or obsessive-compulsive disorder if present

Vertebrobasilar Insufficiency

• Reduce modifiable risk factors (e.g., smoking, hypertension, hyperlipidemia)
• Anticoagulant or antiplatelet agents
• Vascular intervention if indicated

Drug-Induced Vertigo

• Reduction, substitution, or elimination of provoking agent

Drug Therapy

Vertigo

• Vestibular suppressants
  • Meclizine
  • Dose: 12.5–50 mg q.d.-t.i.d.
  • Diazepam
  • Dose: 2–10 mg q.d.-t.i.d.
  • Oxazepam
  • Dose: 5–30 mg q.d.-t.i.d.
  • Clonazepam
  • Dose: 0.5–2 mg q.d.-t.i.d.
• Stimulants: adjunct to vestibular suppressants to reduce sedation
• Caffeine
• Dose: as contained in caffeinated beverages or 50–200 mg daily
• Methylphenidate
• Dose: 5–10 mg q.d.-b.i.d.
• For nausea or vomiting
• Ondansetron
• Dose: 8–24 mg
• Promethazine
• Dose:12.5–25 mg
• Prochlorperazine
• Dose: 25 mg

The author has no commercial relationships with manufacturers of products or providers of services discussed in this module.

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Best References

Brandt T, et al: J Neurol 241:191, 1994 [PMID 8195816]

Cutrer FM, et al: Headache 32:300, 1992 [PMID 1399552]

Furman JM, et al: N Engl J Med 341:1590, 1999 [PMID 10564690]

Halmagayi GM, et al: Otolaryngol Head Neck Surg 111:571, 1994 [PMID 7970794]

Solomon D: Curr Treat Options Neurol 2:417, 2000 [PMID 11096767]

September 2006

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