Vertigo

Question 1

A 68 year old woman presents feeling dizzy and vomiting. She reports intermittent episodes of “the world spinning” over the last 4 days made worse by movement. She is currently vomiting profusely and unable to stand or walk. How would you assess and manage her?

Answer 1

Impression
This woman’’s presentation is vertiginous in nature, there are a number of causes of vertigo to be considered;

DDx

• Central: posterior/brainstem stroke, SOL, vestibular migraine, demyelinating condition
• Peripheral: Vestibular neuritis, BPPV, Menieres disease, seizure
• Syncope/Pre-syncope causes (alternative diagnosis)

Question 2

Vertigo - History

Answer 2

History

• PC: timing, onset of symptoms. Clarify if world spinning, or just sensation of ‘dizziness’ vs other. Timing - acute + persistent is more likely central vs peripheral.
• assoc: raised ICP (early morning vomiting, etc)
• Menieres: tinnitus + hearing loss + vertigo
• vestibular neuritis: preceding viral illness
• migraine: aura, history of migraines, etc
• Stroke: other neurological signs (FAST), weakness, CVD risk factors
• PMHx, medications (recent ototoxic ABx’s)
• Psychosocial - home environment, falls risk
• SNAP

Question 3

Vertigo - Examination

Answer 3

Examination
- General appearance + vitals
- Neurological exam: focal neurological deficits, cerebellar testing (DANISH R, gait)
- HINTS exam (if suspecting central cause)
o Head impulse (if absent then likely central)
o Nystagmus: central = vertical or bidirectional
o Test of skew: vertical corrections = central
- Dix-Hallpike: if thinking BPPV
o can also perform Epley’s manoeuvre for therapeutically

Question 4

Vertigo - Investigations

Answer 4

Investigations
Vertigo is mostly a clinical diagnosis. 
- Bedside: audiometry
- Bloods: EUC, CRP/ESR
- Imaging: MRI Brain if suspicious of central cause

Question 5

Vertigo - Management

Answer 5

Management
Supportive
- Fluids/electrlytes
- analgesia
- antiemetics
- antivertigo meds: antihistamines + benzodiazepines
- patient education (especially if BPPV)

Definitive - depends on underlying cause
- BPPV: referral to physio for therapeutic maneouvres and further patient education - modified employ manoeuvre for posterior canal crystals. Repeat treatment 3x daily until symptom free for 24 hours
- Meniere’s disease:
o salt restriction, limit caffeine intake
o pharmacological: Hydrochlorothiazide +/- amiloride
o antiemetics in acute attack
- Vestibular neuritis: counselling that symptoms will improve over time