Version 2.1 Vertigo 6/05/2012
Definition
Type of dizziness that involves a false sensation that one's self or the surroundings are
spinning, swaying or tilting, usually accompanied by loss of balance & nystagmus (dir=fast phase).
• Peripheral (vestibular) [85%]: e.g. vestibular neuritis, BPPV, Ménière's, ear infections
• Central (CNS) [15%]: e.g. cerebrovascular disease, migraine, MS, acoustic neuroma
Acute vestibular syndrome (AVS)
Acute dizziness with N/V, unsteady gait, nystagmus, intolerance to head motion, and lasts ≥24h,
no focal neuro signs (hemiparesis, hemisensory loss, gaze palsy)
• Most common causes: Vestibular neuritis (labyrinthitis) and vertebrobasilar CVA
• Central causes: Vertebrobasilar CVA (83%), multiple sclerosis (11%), other (6%)
• Over 50% of vertebrobasilar CVA’s have no focal neuro deficit.
• Excludes BPPV and Ménière's (as they tend to have <24h of continuous symptoms)
Epidemiology
• Studies show that about a third of cases of dizziness are vertigo.
• Most common are viral, BPPV or Meniere's disease.
• Prevalence estimates for vertigo are ~5%, for BPPV 1.6%. Meniere's disease ~0.5%
Causes of vertigo
Peripheral Central
Benign paroxysmal positional vertigo Brainstem (vertebrobasilar) ischemia – infarction/dissection
Vestibular neuritis and viral labyrinthitis Cerebellar infarction and haemorrhage
Ménière's disease Multiple sclerosis
Herpes zoster oticus (Ramsay Hunt syndrome) Migrainous vertigo
Drug toxicity - aminoglycosides, salicylates, quinine Chiari malformation
Otitis media Episodic ataxia type 2
Perilymphatic fistula or Semicircular canal dehiscence syndrome
Labyrinthine concussion
Acoustic neuroma
Clinical distinction between central and peripheral vertigo
Peripheral Central
Episode frequency Multiple prodromal episodes of dizziness
Effect of visual fixation Suppressed Not suppressed
Horizontal head impulse test Abnormal vestibular-ocular reflex Normal
Nystagmus Unidirectional, fast phase towards the normal ear; Gaze-evoked nystagmus (fast right-beating on gaze
increases on gazing to normal ear; never reverses. to R, fast left-beating on gaze to L). May be purely
May be horiz or rotatory-vertical. vertical.
Alternate cover test Normal or minor horiz re-fixation Abnormal (vertical refixation = skewed deviation)
Postural instability Unidirectional instability, (usually towards side of Severe instability, patient often falls when walking.
lesion); walking preserved Truncal ataxia – unable to sit with arms folded
Other neurologic signs Absent Often present (e.g. CN palsies, cerebellar signs)
Other features Hallpike +ve (BPPV), ?Nausea & vomiting more severe May have headache/neck pain (esp early morning)
Hallpike Test (~50-90% sensitive)
Tests for canalithiasis of posterior semicircular canal (most common cause of BPPV):
• Sit patient on a flat bed. Hold patient's head turned to side with neck extended.
• Lie patient back quickly, eyes open & head 30° below the horiz & turned 30° to examiner.
• Keep in position for 30s and then return to sitting for another 30s. Rpt on other side.
• Positive if latency (few secs) after lying, vertigo and horiz-rotatory nystagmus towards
affected (lowest) ear for ≤30s. On sitting nystagmus recurs in opposite direction.
• The vertigo and nystagmus fatigue on repetition (but repetition can reduce the chance of
an immediate Epley manoeuvre being successful).
Definition
Type of dizziness that involves a false sensation that one's self or the surroundings are
spinning, swaying or tilting, usually accompanied by loss of balance & nystagmus (dir=fast phase).
• Peripheral (vestibular) [85%]: e.g. vestibular neuritis, BPPV, Ménière's, ear infections
• Central (CNS) [15%]: e.g. cerebrovascular disease, migraine, MS, acoustic neuroma
Acute vestibular syndrome (AVS)
Acute dizziness with N/V, unsteady gait, nystagmus, intolerance to head motion, and lasts ≥24h,
no focal neuro signs (hemiparesis, hemisensory loss, gaze palsy)
• Most common causes: Vestibular neuritis (labyrinthitis) and vertebrobasilar CVA
• Central causes: Vertebrobasilar CVA (83%), multiple sclerosis (11%), other (6%)
• Over 50% of vertebrobasilar CVA’s have no focal neuro deficit.
• Excludes BPPV and Ménière's (as they tend to have <24h of continuous symptoms)
Epidemiology
• Studies show that about a third of cases of dizziness are vertigo.
• Most common are viral, BPPV or Meniere's disease.
• Prevalence estimates for vertigo are ~5%, for BPPV 1.6%. Meniere's disease ~0.5%
Causes of vertigo
Peripheral Central
Benign paroxysmal positional vertigo Brainstem (vertebrobasilar) ischemia – infarction/dissection
Vestibular neuritis and viral labyrinthitis Cerebellar infarction and haemorrhage
Ménière's disease Multiple sclerosis
Herpes zoster oticus (Ramsay Hunt syndrome) Migrainous vertigo
Drug toxicity - aminoglycosides, salicylates, quinine Chiari malformation
Otitis media Episodic ataxia type 2
Perilymphatic fistula or Semicircular canal dehiscence syndrome
Labyrinthine concussion
Acoustic neuroma
Clinical distinction between central and peripheral vertigo
Peripheral Central
Episode frequency Multiple prodromal episodes of dizziness
Effect of visual fixation Suppressed Not suppressed
Horizontal head impulse test Abnormal vestibular-ocular reflex Normal
Nystagmus Unidirectional, fast phase towards the normal ear; Gaze-evoked nystagmus (fast right-beating on gaze
increases on gazing to normal ear; never reverses. to R, fast left-beating on gaze to L). May be purely
May be horiz or rotatory-vertical. vertical.
Alternate cover test Normal or minor horiz re-fixation Abnormal (vertical refixation = skewed deviation)
Postural instability Unidirectional instability, (usually towards side of Severe instability, patient often falls when walking.
lesion); walking preserved Truncal ataxia – unable to sit with arms folded
Other neurologic signs Absent Often present (e.g. CN palsies, cerebellar signs)
Other features Hallpike +ve (BPPV), ?Nausea & vomiting more severe May have headache/neck pain (esp early morning)
Hallpike Test (~50-90% sensitive)
Tests for canalithiasis of posterior semicircular canal (most common cause of BPPV):
• Sit patient on a flat bed. Hold patient's head turned to side with neck extended.
• Lie patient back quickly, eyes open & head 30° below the horiz & turned 30° to examiner.
• Keep in position for 30s and then return to sitting for another 30s. Rpt on other side.
• Positive if latency (few secs) after lying, vertigo and horiz-rotatory nystagmus towards
affected (lowest) ear for ≤30s. On sitting nystagmus recurs in opposite direction.
• The vertigo and nystagmus fatigue on repetition (but repetition can reduce the chance of
an immediate Epley manoeuvre being successful).
