NICE CKS Vertigo guideline (2017)

Definition

Vertigo is a symptom

Vertigo is a false sensation of a person or their surroundings moving or spinning, but with no actual physical movement.

In contrast, dizziness is a perception of disturbed or impaired spatial orientation, but there is no false sense of motion.

Consequences

Vertigo can adversely affect quality of life and independence and affect activities such as driving and employment.

Vertigo also increases the likelihood of falls and anxiety

Clinical subdivision

Peripheral vertigo (inner ear)

More common

Dysfunction of the vestibular labyrinth, semicircular canals or the vestibular nerve

Benign paroxysmal positional vertigo
Vestibular neuronitis
Labyrinthitis
Meniere’s disease
Perilymphatic fistula (post head trauma)
Labyrinthine concussion
Vestibular ototoxicity
Semicircular canal dehiscence syndrome
Syphilis

Red Flag features indicating a central cause of vertigo

sudden onset severe vertigo that is persistent and not provoked by positional change

new-onset headache or recent head trauma

focal neurological deficit (e.g. gait disturbance, truncal ataxia)

additional cranial nerve deficits (besides CN VIII)

vertical nystagmus

acute deafness without other typical features of Meniere’s disease

abnormal response to the Dix-Hallpike manoeuvre

inability to stand up or walk even with the eyes open

cardiovascular risk factors

Central vertigo (brain)

Uncommon

Dysfunction of the cerebral cortex,
cerebellum, or brain stem.

Vestibular migraine
Stroke
Transient ischaemic attack
Cerebellar tumour
Multiple sclerosis
Acoustic neuroma

Assessment of vertigo

Description of the vertigo: onset, duration, frequency

Provocation factors: head or gaze change

Associated symptoms: nausea/vomiting, hearing loss, hearing fullness (Meniere's disease)

Neurological symptoms: headache, diplopia, visual disturbance, dysarthria or dysphagia, paraesthesia, muscle weakness, ataxia, migraine aura, gait disturbance

Relevant medical history –URTI/LRTI/ear infections, migraine, direct head trauma (consider perilymphatic fistula and other central causes)

Cardiovascular risk factors for stroke: previous angina or myocardial infarction, diabetes, hypertension, smoking, atrial fibrillation

Vertigo caused by drugs (such as aminoglycosides, furosemide, antidepressants, antipsychotics) and alcohol

Personal/Family history migraine or Meniere's disease

Peripheral causes:

Benign paroxysmal positional vertigo (BPPV) short duration (30s- 1min), recurrent attacks, accompanied by nausea, triggered by head movement; patient feels normal in between attacks (diagnosed by Dix-Hallpike manoeuvre and treated by Epley's Manoeuvre)

Ménière’s disease medium duration (30min-3h); episodes involve fluctuating hearing loss, vertigo, tinnitus, feeling of fullness in the ear (and nausea/vomiting); episodes occur spontaneously (not triggered by position change); hearing recovers once vertigo has settled; caused by a raised volume of fluid in the labyrinth. Treatment options: restrict salt/caffeine/alcohol, betahistine, surgery.

Long duration (days-weeks) post-viral infection of vestibular nerve or labyrinth; may have spontaneous nystagmus; may take 6w to resolve
Vestibular neuronitis: sudden onset severe vertigo, unsteadiness, nausea and vomiting
Labyrinthitis: sudden onset severe vertigo, vomiting PLUS deafness (without the feeling of fullness in the ear described by patients with Meniere’s disease)
Recovery is much quicker in the long run if treatment with vestibular sedatives is not prolonged

Central causes:

Vestibular migraines ataxia, visual disturbances, occipital pain, nausea and vomiting

Acute vestibular syndrome:

Sudden onset of acute ‘continuous’ vertigo
Duration >24 hours
Associated with nausea and vomiting
Intolerance of head movement
Nystagmus (spontaneous OR gaze-evoked)
Unsteadiness of gait

This can be caused by
80% cases —> peripheral vertigo (e.g.vestibular neuronitis)
20% cases —> central vertigo (e.g. posterior circulation cerebellum or brainstem stroke)

Examination

• Neurological examination:

Eyes CN II – visual fields, acuity
CN III, IV(SO), VI(LR) – diplopia
Nystagmus
Fundoscopy

Facial asymmetry/weakness: CN V, CN VII

Balance and hearing: CN VIII AND
Examination of the ear (discharge, vesicular eruptions (indicating herpes zoster infection) and signs of cholesteatoma (for example a retraction pocket).

Pharynx: CN IX, CN X

Sternocleidomastoid and trapezius muscles: CN XI

Tongue: CN XII

Tests of cerebellar function including heel to toe walking

Examination of gait for gait ataxia

Evidence of dysarthria

Signs of peripheral neuropathy

• Cardiovascular examination BP, pulse, HS 1—2 etc and ABCD2 stroke risk score

Vertigo-specific examination tests

Postural stability

Can walk, some unsteadiness (peripheral cause)

Inability to stand up or walk even with the eyes open (central cause)

Romberg’s test
Romberg positive if cannot maintain balance with eyes closed (indicates proprioception or vestibular dysfunction)

Dix-Hallpike manoeuvre
Test provokes vertigo and nystagmus. Undertake if patient has:

• positional vertigo triggered by moving the head

• vertigo that is short-duration (30s-1min)

• no spontaneous nystagmus

1. Ask the person to sit upright with their head turned 45 degrees to one side.

2. From this position, lie the person down rapidly until their head is extended 20–30 degrees over the end of the couch with the chin pointing slightly upwards and the test ear downwards.

3. Observe their eyes closely for nystagmus.

HINTS+
95% sensitivity and 70% specificity for stroke

If any element indicates a central cause or is inconsistent with a peripheral cause then the aetiology must be assumed to be central until proven otherwise

Undertake if patient has:

• Hours-days of continuous vertigo

• Spontaneous nystagmus

Horizontal HEAD IMPULSE (h-HI)
Fix gaze on examiner, central position; turn patient’s head 20 degrees to one side
Tests integrity of peripheral vestibulo-ocular reflex (VOR)

Normal h-HI (eyes stay fixed, no saccade) = intact VOR (i.e. central cause)

Positive h-HI (eyes show catch-up saccade) = disrupted VOR (i.e. peripheral cause)

NYSTAGMUS

Unidirectional, horizontal nystagmus (peripheral cause)

Direction-changing bidirectional vertical/torsional large-amplitude nystagmus (central cause)

TEST OF SKEW (movement in recently uncovered eye)

Normal response (no vertical skew correction) = intact central system

Abnormal response (upward on one side, downward on the other side) = central vertigo

PLUS HEARING

Unilateral sensorineural hearing loss: labyrinthine ischaemia (stroke, cerebral tumour)

Unterberger’s test
Ask the person to march on the spot with their eyes closed and observe them for lateral rotation.
If there is labyrinthine damage, the person will rotate to the side of the affected/weakened labyrinth.

MANAGEMENT

1. Short-term vestibular sedative drug treatment

To relieve symptoms of nausea and vomiting

buccal prochlorperazine
i.m. prochlorperazine or cyclizine
oral prochlorperazine or promethazine teoclate (antihistamine)

Avoid long-term prescription of vestibular sedatives as they prolong the body’s readjustment after an instance of vertigo.

2.Management of central vertigo

Admit to Hospital for suspected central vertigo or suspected vestibular migraine (new-onset headache combined with vertigo could represent vestibular migraine OR brainstem CVA)

Assessment by neurology/ENT: investigations considered: hearing tests, tests of balance, MRI scan or CT scan

Consider commencing migraine treatment only if patient known to have a diagnosis of vestibular migraine

Consider short-term vestibular sedative drug treatment to relieve symptoms of nausea and vomiting.

3.Management of peripheral vertigo

Refer to a balance specialist (ear, nose, and throat specialist, audiovestibular physician, neurologist).
The urgency of referral will depend on the person's symptoms, clinical findings, and clinical judgement.

Consider short-term vestibular sedative drug treatment to relieve symptoms of nausea and vomiting.

Epley manoeuvre:

If the patient has BPPV and a positive Dix-Hallpike test, the Epley manoeuvre is indicated.
It can also be performed immediately after diagnostic tests and can be repeated if necessary to relieve symptoms.
74% of patients have total resolution of their symptoms within a week of the manoeuvre.

Brandt-Daroff:

This is recommended if CRPs are ineffective or not suitable.
Brandt-Daroff is a treatment for BPPV that can be performed at home without supervision.
The repetitive movements encourage the otoconia to move back to their correct position in the inner ear.

Chronic vertigo requiring vestibular rehabilitation

Cawthorne-Cooksey exercises promote central compensation for vestibular dysfunction and offer treatment for chronic vertigo.
Doing this may make the dizziness symptoms worse for a few days after the exercises, but perseverance may help to alleviate the symptoms over time.
BPPV and Ménière’s disease may not respond well to vestibular rehabilitation.