Articles
Diagnosis, treatment and management of UTI in children (D&G) Hospital at Home (H@H) Infant hip clinic referral form Vaccination referral form Assessment and management of babies who are accidentally dropped in hospital DGRI NNU Guideline for Management of Cord Blood Gas Results NNU Admission Criteria Antenatal Drugs for NAS Monitoring Vaccination Referrals from ED Paediatric Antimicrobial Guidance Children’s Services Resolution and Escalation Protocol Blunt Chest Wall Trauma/Rib Fractures Information for Parents Carers of Children Having Investigations in Relation to Unexplained Injuries + Consent form Bruising and Injuries in Babies and Children – Parents Leaflet Multi-Agency Protocol for Injuries to Non-Mobile Children Flowchart for children attending Galloway Community Hospital (GCH) for NAI Follow Up Skeletal Survey Flowchart for children attending DGRI for NAI Follow-Up Skeletal Survey Cognitive Function Conscious Level Kidney Biopsy Complications Parenteral Iron for Non-HD CKD Patients Fracture Management Guidelines (Paediatric) Fracture Management Guidelines (Adult) Management of Hypertension in Acute Stroke Prescribing for CAU Patients Still in ED Hypothermia Deactivation of Implantable Cardioverter Defibrillator Myeloma Croup Care Of Burns In Scotland (COBIS) Paediatric Guidance Management of Epistaxis Sore Throat Differential Diagnosis Dizziness Differential Diagnosis Peritonsillar Abscess/Quinsy Acute Tonsillitis Acute Mastoiditis Otitis Media Otitis Externa Extravasation of IV Amiodarone WoS Paediatric Drooling and Aspiration Guideline Palliative Care – How to Refer Eating Disorders Stroke Care Warfarin Anticoagulation for AF, DVT and PE Molnupiravir MyPsych Foundation Doctors Toolkit Paediatric Febrile Neutropenia Guidance PAEDIATRIC HYPOGLYCAEMIA MANAGEMENT in NON DIABETIC CHILDREN   Paediatric Diabetic Ketoacidosis (DKA) Guideline Child Protection Policies and Procedures (D&G) Management of Acute Behavioural Challenges in Adolescents and Young People presenting to Secondary Care Cancer of Unknown Primary Patients Returning from Interventional Cardiac Procedure Treatment of Malaria Discharging Patients on High Dose Steroids Sotrovimab Paediatric Ketone Correction Guideline Insulin Correction Factor Table (Paediatrics) Management of uncomplicated Henoch-Schonlein Purpura (HSP) in under 16s Management of Hypoglycaemia in Children with Type 1 Diabetes Newly diagnosed diabetic – not in DKA (Walking wounded) Proton Pump Inhibitor Guideline for Neonatal and Paediatrics Stroke – Post Thrombolysis Neonatal Guidelines Gentamicin Prescribing (Paediatrics) Management of Anaphylaxis (Paediatrics) Management of Prolonged Seizures (Convulsive Status Epilepticus) in Children Bronchiolitis Acute Wheeze or Asthma in Paediatrics Conscious Proning Covid-19 Basics Remdesivir Thromboprophylaxis Identifying Patients in the Highest Risk Groups Steroids for Patients with Covid-19 Infection IL-6 Inhibitors – Tocilizumab or Sarilumab Baricitinib Paxlovid (Nirmatrelvir/Ritonavir) Influenza A Inhalers for Adults with Asthma Standard Operating Procedure for AMU Trigger Finger/Thumb Osteoarthritis of the Hand/Thumb Mallet Finger Ganglion Dupuytren’s Contracture De Quervain’s Tenosynovitis Carpal Tunnel Syndrome Prescribing Advice on Admission – Clozapine Prescribing Advice on Admission – Methadone/Buprenorphine Prescribing Advice on Admission – Corticosteroids Prescribing Advice on Admission – Items Not Prescribed by GP Prescribing Advice on Admission – Patients on Chemotherapy Regimes Prescribing Advice on Admission – Medication for Parkinson’s Disease Prescribing Advice on Admission – Insulin Prescribing Advice on Admission Medical Emergencies in Eating Disorders (MEED) Gentamicin & Vancomycin HIV Testing Guidelines Metabolic Syndrome Associated Fatty Liver Disease (MAFLD) Greener Inhaler Prescribing C4 Predischarge Beds Handover Safe and Secure Handling of Medicines Blood Glucose & Steroids IV Fentanyl & Morphine for Acute Pain in Adults Assessment & Management of Acute Pain Hospitalised and Has Coronavirus19 Infection (No suspected Viral Pneumonia Syndrome) Hospitalised Due to Coronavirus19 with Likely Viral Pneumonia Bi-Level NIV S/T Guidelines for CCU Phase Bi-Level NIV S/T Guidelines for ED Phase Adults With Incapacity Premenstrual Syndrome Pelvic USS Boarding Coeliac diagnosis pathway (Adults) Voice clinic Ear Wax Dermatology Squamous Cell Carcinoma (SCC) Malignant Melanoma Basal Cell Carcinoma (BCC) Nipple Discharge Early Cancer Diagnostic Clinic (ECDC) Genetics Referrals Breast Infections Breast Pain Primary Care Prescribing Guidelines Emergency Department Anaesthetics and Chronic Pain Team Respiratory Referrals Chronic Cough Pathway GP Clinical Handbook Test Paediatric Bronchiolitis Early Cancer Diagnosis Clinic (ECDC) Obstetrics & Gynaecology/Medicine Admission Agreement Idiopathic Intrancranial Hypertension Urology Out of Hours Urology Out of Hours Sengstaken/Minnesota Tube for Bleeding Varices Eradication of Helicobacter pylori Transfer from Galloway Community Hospital Repatriation of Patients from Tertiary Hospitals THROMBOPROPHYLAXIS IN PREGNANCY – Appendix 1, Risk factors THROMBOPROPHYLAXIS IN PREGNANCY – Appendix 3, Postnatal assessment & management THROMBOPROPHYLAXIS IN PREGNANCY – Appendix 4 THROMBOPROPHYLAXIS IN PREGNANCY – Appendix 2, Management of women with previous VTE THROMBOPROPHYLAXIS IN PREGNANCY, LABOUR AND THE PUERPERIUM Orthopaedic VTE Risk Assessment Sodium Glucose Transporter 2 Inhibitors (SGLT2i) Cardiology Referrals Vascular Referrals ‘Watershed’ Conditions Myasthenia Gravis Gentamicin in Renal Replacement Therapy Vancomycin in Renal Replacement Therapy REDMAP Poster Realistic Conversations Summary Plan for Deteriorating Health Treatment Escalation Plans Ambulatory Care for Blood and/or Iron Infusion Principles for Light Touch Patients – B2 Clostridiodes difficile Infection Post Astra Zeneca Vaccine Headache Blood Culture Rhabdomyolysis Analgesia Acute Appendicitis Small Bowel Obstruction Elective Admission – Colorectal Surgery Trauma Admissions Post-operative Care Gallstone Disease Vasopressors and Inotropes/Chronotropes Shock Elective Admission – ERCP Elective Admission – Orthopaedics Laxatives Fat Embolism Compartment Syndrome Surgical Post-operative Complications Stoma Diverticular Disease High Dose Steroid Pre-Treatment Checklist Acute Surgical Admissions Level 1 CCU Medical Area Acute Oncology STEMI Thrombolysis Protocol Haemolytic Anaemia Conversion Charts Anticipatory ‘As Required’ Medications Syringe Driver Chart Scottish Palliative Care Guidelines Covid-19 Sick Day Rules for Patients with Primary Adrenal Insufficiency Diabetic Retinopathy Coming Off Benzodiazepines and “Z” Drugs Dental Abscess Facial Trauma – Mandibular Fractures Facial Trauma – Orbital Fractures Facial Trauma – Zygoma Platelet Transfusion Death Certification Parenteral Iron in Adults >18 Years OPAT SBAR (Complex Infections) Mental Health Liaison Team Referrals STEMI Admitting Patients with Tracheostomy/Laryngectomy to DGRI Emergency Laryngectomy Management Emergency Tracheostomy Management Safe Transfer of Patients with Tracheostomy/Laryngectomy within DGRI Other Tracheostomy Documents Systemic Anticancer Therapy Toxicity Haemodialysis Medication Prescribing Breaking Bad News by Telephone End of Life Diabetes Care Adrenal Insufficiency Serotonin Syndrome DGRI Referrals Confirmation of Death Neuroleptic Malignant Syndrome Pulmonary Embolism Deep Vein Thrombosis of Lower Extremities Exacerbation of COPD Contrast Associated AKI Paracetamol Hypertensive Emergencies Staphylococcus aureus Bacteraemia (SAB) Rate Control in AF Common Scenarios Acute Severe Ulcerative Colitis IV Fluid Prescription in Adults Chronic Obstructive Pulmonary Disease Legionnaires Disease Septic Arthritis Guillain-Barré Syndrome Back Pain Anaesthetics – Unscheduled Procedures Requests Hyperglycaemia & Steroids Variable Rate Insulin Infusion Decompensated Liver Disease Fast Atrial Fibrillation – ACP Hyperkalaemia Contraindications to MRI Magnetic Resonance Imaging Bleeding with Other Antithrombotics In-patient Hyperglycaemia Management Anaemia (Management) – ACP Suspected NSTEMI – ACP Guidance on Chaperones Compulsory Admission and Treatment Radiology Immediate Discharge Letter Alcohol Withdrawal Fentanyl Patches in the Last Days of Life Care in the Last Days of Life Low Molecular Weight Heparin Interstitial Lung Disease Haematinic Testing Thromboprophylaxis for Non-Covid Patients Lung Cancer Osteoporosis Heart Failure Fluid Replacement in AKI Death & The Procurator Fiscal Thrombophilia Screening Neutropenic Sepsis Acute Vertigo Aortic Dissection Antithrombotics in Hip Fracture Transient Global Amnesia Hypomagnesaemia Hypophosphataemia Oxygen Therapy Falls – ACP Falls Acute Asthma Oncology Contact Details & General Advice Reversal of Warfarin Lumbar Puncture, Antiplatelet & Anticoagulant Drugs Antithrombotics & Surgery Non ST Elevation MI (NSTEMI) Suspected Acute Coronary Syndrome Antibiotics and the Kidney Acute Upper GI Bleeding (AUGIB) Pericardiocentesis Pleural Effusion Spontaneous Pneumothorax Acute Diarrhoea Iron Deficiency Anaemia Hyperthyroidism Gout Giant Cell Arteritis Pacemakers Clinical Suspicion PE – ACP Community Acquired Pneumonia (CAP) Management of Urinary Symptoms Acute Kidney Injury (AKI) SSRI Poisoning Immobility Autopsies Indications for Echocardiography Bradycardia Suspected Meningitis Hypernatraemia Diarrhoea – ACP Suspected Meningitis – ACP Blood Transfusion Brain Tumours Newer Antidiabetic Drugs Parkinson’s Disease Major Haemorrhage Protocols (DGRI & GCH) Major Haemorrhage Stroke Thrombolysis Pneumothorax – ACP Heart Failure – ACP Suspected Anaphylaxis Anaphylaxis – ACP The AMB Score – ACP Transient Loss of Consciousness (TLOC) – ACP Bell’s Palsy – ACP Suspected Sepsis Lumbar Puncture Hypokalaemia Gentamicin Dosing Transient Loss of Consciousness Urinary Tract Infection Urethral Catheterisation Vancomycin Dosing Hyponatraemia Narrow Complex Tachycardia Hypocalcaemia New Onset Type 1 Diabetes – ACP Paracentesis for Tense Ascites – ACP Idiopathic Intracranial Hypertension – ACP Other Funny Turns Hypoglycaemia Hypoglycaemia – ACP Management of Transfusion Reactions Hypercalcaemia Haematemesis – ACP Anti-Platelet Therapy in Coronary Heart Disease Unfractionated Heparin Infusion Anaemia (Investigation) – ACP Delirium Suspected Seizure – ACP Headache – ACP Community Acquired Pneumonia – ACP Cellulitis Dyspepsia Management of Acute AF Rhythm Control in AF Atrial Fibrillation Kidney Transplantation Massive Pulmonary Embolism Head and Neck Injury Diabetic Ketoacidosis Switching from VRII Insulin Pumps Diabetes Mellitus Aspirin Digoxin Poisoning Tricyclic Antidepressants Opiates Benzodiazepines Gut Decontamination Deliberate Self Harm Acute Liver Failure Asymptomatic Raised Transaminases (ALT & AST) Nutritional Support in Adults Refeeding Syndrome Parenteral Nutrition Crohn’s Disease Acute Pancreatitis Abdominal Aortic Aneurysms Malignant Spinal Cord Compression Post Splenectomy Sepsis Ascites in Cirrhosis Alcohol Related Liver Disease Hepatitis C Symptom Control Suspected Variceal Bleeding Severe Headache Status Epilepsy in Adults Lower Gastrointestinal Bleeding Functional & Social Assessment Breathlessness with Abnormal CXR Polymyalgia Rheumatica Rheumatoid Arthritis Ureteric Colic & Renal Stones Intravascular Catheter Related Blood Stream Infection Care of Vascular Access Urinary Incontinence Peritoneal Dialysis Related Peritonitis The First Seizure Hypertension Ventricular Tachycardia Cardiogenic Shock Complicating Acute Coronary Syndrome Telemetry The Diabetic Foot Subcutaneous Insulin Diabetes and Acute Coronary Syndrome Hyperosmolar Hyperglycaemic State Multiple Sclerosis Coma
 
Close Menu
 
 
In this section Close
In this section : Neurology
Cognitive Function Conscious Level Stroke Care Idiopathic Intrancranial Hypertension Myasthenia Gravis Serotonin Syndrome Neuroleptic Malignant Syndrome Guillain-Barré Syndrome Acute Vertigo Transient Global Amnesia Brain Tumours Lumbar Puncture Transient Loss of Consciousness Other Funny Turns Haematemesis – ACP Head and Neck Injury Severe Headache Status Epilepsy in Adults The First Seizure Multiple Sclerosis Coma
Home | Articles | Neurology | Acute Vertigo

Acute Vertigo

Last updated 28th February 2022

Structures of the Vestibular Apparatus. This work by Cenveo is licensed under a Creative Commons Attribution 3.0 United States (http://creativecommons.org/licenses/by/3.0/us/).

What is Meant by Vertigo?

  1. Vertigo means a spinning sensation or false sense of motion
  2. Causes are either peripheral (vestibular +/- cochlear division 8th cranial nerve), or central (cerebellopontine angle, brain stem or cerebellum)
  3. Vomiting frequently accompanies vertigo of any kind
  4. Peripheral causes often (but not always) accompanied by tinnitus and deafness
  5. Nystagmus is the principal sign – horizontal can be peripheral or brain stem but vertical typically mean a central lesion
  6. Central causes usually have other clinical signs eg diplopia, cranial nerve palsies, cerebellar or long tract signs.

Differential Diagnosis

  1. Patients with vertigo will usually complain of dizziness
  2. Should ask patient whether they experience a feeling of rotation OR if they are light headed as if about to faint OR simply unsteady on their feet
  3. It’s often more difficult to do this than you might think
  4. If they don’t feel sick it’s probably not vertigo

Benign Positional Paroxysmal Vertigo (BPPV)

  1. A peripheral vestibular disorder characterised by sudden onset, severe attacks of vertigo usually lasting <30 seconds and precipitated by specific head movements eg looking up or bending down, getting up, turning the head or rolling over to one side in bed.
  2. It occurs when calcium carbonate crystals that are normally embedded in gel in the utricle become dislodged and migrate into one or more of the three fluid-filled semicircular canals.  When enough of these particles accumulate in one of the canals they interfere with the normal fluid movement that these canals use to sense head motion, causing the inner ear to send false signals to the brain.
  3. Diagnosis is clinical with key diagnostic features that include episodic vertigo (repeated attacks over days, weeks or months), absence of tinnitus or hearing loss, normal neuro exam, positive Dix-Hallpike manoeuvre and normal otological exam.
  4. Treatment is Epley’s manoeuvre

Vestibular Neuritis

  1. Vestibular neuritis (aka vestibular neuronitis) occurs when an infection (usually viral) affects the vestibular branch of the 8th nerve, resulting in acute vertigo but no tinnitus or hearing loss.
  2. Vertigo can range from mild to severe and is associated with nausea and/or vomiting. If patient doesnt feel sick then it’s probably not vertigo.  Symptoms can also include unsteadiness,  imbalance and impaired concentration.
  3. Symptoms will last at least 24 hours and may go on for weeks if untreated.
  4. Early treatment with steroids has been shown to accelerate recovery

Labyrinthitis

  1. Labyrinthitis occurs when an infection affects both branches of the 8th nerve
  2. Viral infections of the inner ear are more common than bacterial.
  3. Viral labyrinthitis is typically associated with a preceding URTI.  Other viral causes include VZV, CMV, mumps, measles, rubella and HIV.
  4. Bacterial labyrinthitis is associated with acute or chronic otitis media, meningitis and cholesteatoma.
  5. Symptoms are the same as for vestibular neuritis but with tinnitus and/or hearing loss
  6. Most episodes last for hours rather than days (which distinguishes labyrinthitis from vestibular neuritis.
  7. Treatment is symptomatic with vestibular suppressants and anti-emetics

Vestibular Migraine

  1. A common cause of vertigo and the most common cause of spontaneous episodic vertigo.
  2. Migraine usually causes severe headache followed by a period of feeling completely washed out.  However many migraine patients have no headache, their predominant symptom instead being vertigo or dizziness/dysequilibrium, confusion, disorientation, dysarthria, visual distortion or altered visual clarity, or limb weakness.
  3. Management is similar to the recommended treatment of migraine headaches, and includes dietary and lifestyle modifications, and prophylactic therapies (beta blockers, calcium channel blockers and tricyclic antidepressants).

Meniere’s Disease

  1. Auditory disease characterised by episodic, sudden onset vertigo with hearing loss and roaring tinnitus and a sensation of pressure or discomfort in the affected ear.
  2. Vertigo lasts minutes to hours and may be associated with nausea and vomiting.  Hearing and tinnitus return to normal in between attacks.
  3. Risk factors for MD include age >40 years, family history, recent viral illness and autoimmune disorders
  4. Treatment is with betahistine 16-24mg tds.  Cinnarizine can be given if doesn’t tolerate betahistine.
  5. Thiazide diuretics (which reduce endolymph) are recommended for patients with recurrent attacks not controlled by betahistine or cinnarizine.
  6. Vestibular and balance rehab is recommended for patients who have problems with balance

Post-traumatic Vertigo

  1. Typically occurs as a result of blunt trauma as a result of a fall, an assault or a motor vehicle accident.  Other causes are postsurgical (middle ear surgery or cochlear implantation) and diving.
  2. Patients may complain of vertigo, dysequilibrium, tinnitus, pressure, headache and diplopia.
  3. Nearly all these patients experience BPPV long term

Cerebrovascular Causes

  1. Cerebellar stroke due to infarction or haemorrhage may present in a similar fashion to peripheral causes of vertigo with suddent intense vertigo, nausea and vomiting.  Bilateral or vertical nystagmus may suggest a central cause.  Other neuro signs include limb ataxia and impaired gait.
  2. Lateral medullary syndrome – acute vertigo with ipsilateral loss of sensation on face, contralateral loss of sensation and power in limbs, suggests lateral medullary or Wallenberg’s Syndrome (thrombosis of the posterior inferior cerebellar artery).
  3. Patients with cerebellar stroke usually cannot stand without support, even with their eyes open, whereas a patient with acute vestibular neuritis or labyrinthitis is usually able to do so.
  4. Unlike peripheral causes the head impulse test is negative (no saccadic adjustment of the eyes on sudden head twisting).
  5. CT head will show haemorrhage but is poor at showing posterior fossa infarction.  Urgent MRI should be requested in all patients with acute vertigo who have significant focal neuro suggesting posterior circulation stroke whose CT head scan is normal

Neoplastic Causes

  1. Posterior fossa tumours may present with vertigo and gait abnormality as well as other symptoms suggesting raised intracranial pressure eg headache, altered mental status, nausea and/or vomiting.
  2. Acoustic neuroma is suggested by unilateral progressive vertigo with tinnitus and hearing loss +/= involvement of cranial nerves 5,6 and 7 at the cerebellar pontine angle.
  3. Neuroimaging with CT/MRI is essential.

Dix-Hallpike Test

  1. Sit patient on bed so that when lying down their shoulders will be level with the end of the bed.
  2. Start with ear that is least expected to be the problem.  If no evidence laterality then it doesn’t matter which ear is tested first.  Using both hands turn head to 45 degrees.
  3. Ask patient to fix eyes on a point directly in front of them throughout the test.
  4. On count of three bring head back quickly over the end of the bed so that it is hanging 15-20 degrees below the horizontal.
  5. Maintain this position for 30-60 seconds observing for vertigo and nystagmus.
  6. On count of three bring patient slowly back to sitting position while maintaining head position at 45 degrees rotation, again observing for vertigo and nystagmus.
  7. Repeat with head turned 45 degrees to other side
  8. Test is negative if no nystagmus observed in either sitting or lying positions
  9. Test supports BPPV if produces vertigo and nystagmus after intial delay.
  10. Nystagmus with no initial delay suggests central cause.

Head Impulse Test

  1. This is a sensitive and specific test which detects unilateral hypofunction of the peripheral vestibular system caused mainly by labyrinthitis or vestibular neuritis
  2. To perform the test, instruct the patient to maintain fixation on the examiner’s nose, then rotate the patient’s head slowly to each side, then briskly back to midline, or from midline to each side.
  3. Normally, the vestibular-ocular reflex(VOR) is able to match the velocity of head rotation and fixation never leaves the nose.
  4. With a vestibulopathy on the side to which the head is quickly rotated, the impaired VOR causes the eyes to lag behind during the rapid head movement, fixation is lost and a rapid corrective eye movement (known as a saccade) back to the target occurs.
  5. The catch up saccade indicates peripheral vestibular hypofunction on the side towards which the head was rotated
  6. This test can be difficult to interpret in an older patients who struggles to follow your instructions

Unterberger Test

  1. This is a simple test to identify which labyrinth is affected in a patient with peripheral vertigo
  2. Patient walks on spot with arms forward at shoulder height and eyes closed
  3. Positive if rotates to one side by greater than 30 degrees in 30 seconds, indicating problem in ear on the side to which rotates
  4. The arm on the side to which they rotate will often drop.
  5. If ataxic or staggers during test then problem is in brain stem or cerebellum

Epley Manoeuvre

  1. Involves gentle but specific manipulation and rotation of patient’s head to shift the loose otoliths from the semicircular canals – refer to ENT

Management of Acute Vertigo

  1. Prochlorperazine 12.5 mg IM tds if vomiting.
  2. Prochlorperazine 5 – 10 mg tds orally if not vomiting.
  3. When acute rotation subsides reduce dose to 5 mg tds orally for further 7 days.
  4. IV fluids if vomiting.
  5. Bed rest and find position of least distress.

Dizzy Dogma

  1. Momentary – non organic, therefore reassure.
  2. Seconds to minutes – BPPV
  3. Minutes to hours – Meniere’s.
  4. Hours – labyrinthitis, vestibular migraine
  5. Days – vestibular neuronitis

Referral to ENT

  1. Refer for Epley manoeuvre
  2. Refer for follow up review at around 6/52 if acute attack vertigo ± tinnitus, hearing loss
  3. Refer urgently for acute total deafness in one ear ± vertigo

Links

  1. Chronic Vertigo Article in BMJ 2017; 358:j3727 – For Full Text, Click to login with OpenAthens and use your Knowledge Network Details
  2. Making a diagnosis in patients who present with vertigo. BMJ 2012;345:e5809 – For Full Text, Clicm to login with OpenAthens and use your Knowledge Network Details