Vertigo

The standard differential for episodic/recurrent vertigo, gathered here for side-by-side comparison.

BPPV (benign paroxysmal positional vertigo)

The most common cause of vertigo. Caused by displaced calcium crystals (otoconia) in the posterior semicircular canal.

Presentation: brief episodes of vertigo with nausea and nystagmus, triggered by rapid position changes.

Examination: nystagmus is rotational; Dix-Hallpike positive.

Investigations: none required.

Management:

• Epley manoeuvre or Semont manoeuvre — first-line.
• Brandt-Daroff exercises — for home repetition if symptoms recur; teach patients to perform them independently.
• Antiemetics if nausea is severe.
• Refer to physiotherapy for vestibular rehabilitation.
• Refractory cases: refer for specialist assessment.

Symptoms recur in 20–30% of cases.

Meniere’s disease

Uncommon. Thought to be caused by increased endolymph in the cochlea.

Demographics: women > men, increasing incidence with age (especially >60 years).

Presentation: spontaneous vertigo lasting >20 minutes, tinnitus, sensorineural hearing loss, aural fullness — hearing loss may become permanent.

Examination: Dix-Hallpike is normal; no nystagmus between attacks.

Management:

Acute vertigo (symptomatic):

• Prochlorperazine 5–10mg PO 6–8-hourly for up to 2 days (Stemetil)
• Promethazine 25–50mg PO 8–12-hourly for up to 2 days (Phenergan)
• Second-line: ondansetron 4–8mg TDS up to 2 days, or diazepam 5mg TDS 2 days

Prophylaxis (improves vertigo; tinnitus/hearing loss are generally unresponsive):

• Hydrochlorothiazide 25mg daily, increasing to 50mg daily
• Reduce salt intake to ≤3g/day
• Avoid caffeine

Betahistine is widely used, but a 2016 RCT (BEMED trial, BMJ) found no benefit over placebo.

Vestibular neuronitis / labyrinthitis

Vestibular neuronitis: inflammation of the vestibular nerve — may follow a respiratory infection or be associated with HSV-1 reactivation.

Presentation: acute/subacute severe rotational vertigo lasting seconds to minutes; nausea; postural imbalance more prominent than with other vertigo causes; no hearing loss.

Examination: mixed horizontal/torsional nystagmus, positive head impulse test, Dix-Hallpike negative.

Management: self-limiting, improving over hours to days.

• Nausea/vomiting — as for Meniere’s disease (prochlorperazine, promethazine; second-line ondansetron or diazepam).
• Steroids may hasten recovery — reserve for severe cases: prednisolone 1mg/kg (max 75mg) for 5 days, then taper over 15 days (20 days total).

Labyrinthitis: inflammation of the labyrinth, usually preceded by a URTI or middle ear infection.

Presentation: episodes lasting seconds to minutes, provoked by head movement, following a preceding URTI/middle ear infection; symptoms last days to weeks; hearing loss is associated (distinguishing it from vestibular neuronitis).

Examination: sensorineural hearing loss.

Management: acute antiemetic treatment; if acute otitis media is present, discuss drainage with ENT via the emergency department.

Vestibular migraine

Causes episodic, spontaneous vertigo — vertigo accompanies migraine headache in about 25% of patients, and can occur before, during or between headaches. Headache is not always prominent — other presentations include positional vertigo and chronic fluctuating vertigo with motion sickness/sensitivity. Auditory symptoms (other than phonophobia) are unusual.

Management:

• Symptomatic treatment of vertigo is often helpful.
• Migraine prophylaxis reduces frequency and severity of vestibular migraine attacks (see migraine for prophylactic agents).
• Anecdotal evidence suggests triptan therapy (as for acute migraine attacks) may relieve vertigo due to vestibular migraine in some patients.

Acoustic neuroma

Uncommon — also known as vestibular schwannoma. A benign, slow-growing tumour of the vestibulocochlear nerve. More common in neurofibromatosis type 2.

Presentation: unilateral tinnitus, unilateral hearing loss, unsteady gait.

Always investigate unilateral tinnitus or unilateral sensorineural hearing loss for acoustic neuroma.

Investigation: MRI brain.

Treatment: surgical removal (neurosurgery/ENT) or stereotactic radiotherapy.