1.11 Vertigo ("Dizzy, lightheaded")
Presentation This may be a nonspecific complaint which must be refined
further into either an altered somatic sensation (giddiness, wooziness);
orthostatic blood pressure changes (lightheadedness, sensation of fainting);
or the sensation of the environment (or patient) spinning (true vertigo).
In inner ear disease, vertigo is virtually always accompanied by nystagmus,
which is the ocular compensation for the unreal sensation of spinning;
but the nystagmus may be extinguished when the eyes are open and fixed on
some point (by the same token, vertigo is usually worse with the eyes closed).
Nausea and vomiting are common accompanying symptoms, but less common
(depending on the underlying cause) are hearing changes, tinnitus, cerebellar
or adjacent cranial nerve impairment.
What to do:
- Have the patient tell you in his own words what it feels like (without
using the word "dizzy"). Ask about any sensation of spinning, factors which
make it better or worse, and associated symptoms. Ask about drugs or toxins
which could be responsible.
- Determine whether the patient is describing vertigo (a feeling of movement
of one's body or surroundings) or a sensation of an impending faint or a
vague unsteady feeling.
- If the problem is near syncope or orthostatic lightneadedness, then
consider potentially serious etiologies such as heart disease, cardiac dys-
rhythmias or blood loss.
- With a sensation of dysequilibrium or an elderly patient's feeling that he
is going to fall, look for peripheral neuropathy, cervical spondylosis, stiff
legs and vasodilator medication. These patients should be referred to their
primary care physicians for management of their underlying medical problems
and adjustment of their medications.
- If there is light-headedness that is unrelated to changes in position and
posture and there is no evidence of disease found on physical examination and
laboratory evaluation, then instruct the patient to hyperventilate by
breathing deeply in and out fifteen times. If this reproduces the symptoms,
assess the patient's emotional state as a possible cause of his symptoms.
- If the patient is having true vertigo, examine for nystagmus, which can be
horizontal, vertical or rotatory (pupils describe arcs). Have the patient
follow your finger with his eyes as it moves a few degrees to the left and
right (not to extremes of gaze) and watch whether there are more than the
normal 2 to 3 beats of nystagmus before the eyes are still. You may detect
nystagmus when the eyes are closed by watching the bulge of the cornea moving
under the lid.
- If nystagmus is not clearly evident and the patient can tolerate it,
attempt a provocative maneuver for positional nystagmus by having the patient
sit up and then lie back, quickly hang his head over the stretcher side
and turn his head and eyes to one side. Repeat to the other side. When this
maneuver produces positional nystagmus, it indicates a benign inner ear
dysfunction. A negative test is not helpful.
- Examine ears for cerumen, foreign bodies, otitis media, and hearing loss.
- Examine the cranial nerves. Test cerebellar function (rapid alternating
movement, finger-nose, gait). Check the corneal blink reflexes: if absent on
one side in a patient who does not wear contact lenses, consider acoustic
- Decide, on the basis of the above, whether the etiology is central
(brainstem, cerebellopontine angle tumor, multiple sclerosis) or peripheral
(vestibular organs, eighth nerve). Central lesions may require further workup,
otolaryngologic or neurologic consultation, or hospital admission, while
peripheral lesions, although more symptomatic, are more likely self-limiting.
- In the emergency department, treat moderate to severe symptoms of vertigo
with intravenous diazepam (Valium) 10 mg or diphenhydramine (Benadryl) 50mg.
Add promethazine (Phenergan) 25mg iv for nausea. If there are no contra-
indications (e.g. glaucoma) then a patch of transdermal scopolamine can be
worn for three days. Some authors recommend hydroxyzine (Vistaril, Atarax)
while others suggest corticosteroids (Solu-Medrol, Prednisone). Nifedipine
(Procardia) had been used to alleviate notion sickness but is no better than
scopolamine patches, and should not be used for patients with postural
hypotension or who take beta blockers. If the patient does not respond, he
may require hospitalization for further parenteral treatment.
- Treat vertigo symptoms in outpatients with diazepam (Valium) 5-10mg qid,
meclizine (Antivert) 12.5-25mg qid, diphenhydramine (Dramamine, Benadryl)
25-50mg qid, promethazine (Phenergan) 25mg qid,or hydroxyzine (Vistaril) 25mg
qid, and bedrest as needed until symptoms improve.
- Arrange for followup if there is no clear improvement in 2 days or if there
is any suggestion of a central etiology.
What not to do:
- Do not attempt provocative maneuvers if the patient is symptomatic with
- Do not give anti-vertigo drugs to elderly patients with dysequilibrium.
These medications have sedative properties which can make them worse.
- Do not make the diagnosis of Meniere's disease (endolymphatic hydrops)
without the triad of paroxysmal vertigo, sensorineural deafness, and tinnitus,
along with a feeling of pressure or fullness in the affected ear.
Discussion In general, the more violent and spinning the sensation of
vertigo, the more likely the lesion if peripheral. Central lesions tend to
cause less intense vertigo and more vague symptoms. Peripheral etiologies of
vertigo or nystagmus include irritation of the ear (utricle, saccule, semi-
circular canals) or the vestibular division of the eighth cranial (acoustic)
nerve by toxins otitis, viral infection, or cerumen or a foreign body against
the tympanic membrane. The term "labyrinthitis" should be reserved for
vertigo with hearing changes, and "vestibular neuronitis" for the common
short-lived vertigo without hearing changes usually associated with viral
upper respiratory infections. Paroxysmal positional vertigo may be related to
dislocated otoconia in the utricle and saccule. If it occurs following trauma,
suspect a basal skull fracture with leakage of endolymph or perilymph, and
consider otolaryngologic referral for further evaluation and positional
Central etiologies include multiple sclerosis, temporal lobe epilepsy,
basilar migraine and hemorrhage in the posterior fossa. A slow-growing
acoustic neuroma in the cerebellopontine angle usually does not present with
acute vertigo but rather a progressive unilateral hearing loss with or
without tinnitus. The earliest sign is usually a gradual loss of auditory
Vertebrobasilar arterial insufficiency can cause vertigo, usually with
associated nausea, vomiting and cranial nerve or cerebellar signs. It
is commonly diagnosed in dizzy pateints who are older than 50, but more often
than not the diagnosis is incorrect. The brainstem is a tightly-packed
structure in which the vestibular nuclei are crowded in with the oculomotor
nuclei, the medial longitudinal fasiculus, cerebellar, sensory and motor
pathways. It would be unusual for ischmia to produce only vertigo without
accompanying diplopia, ataxia, sensory or motor disturbance. Although vertigo
may be the major symptom of an ischemic attack, careful questioning of the
patient commonly uncovers symptoms implicating involvement of other brainstem
structures. Objective neurologic signs should be present in frank infarction
of the brainstem.
Either central or peripheral nystagmus can be due to toxins, most commonly
alcohol, tobacco, aminoglycosides, minocycline, disopyramide, phencyclidine,
phenytoin, benzodiazepines, quinine, quinidine, aspirin, salicylates, non-
steroidal anti-inflammatories and carbon monoxide.
Nystagmus occuring in central nervous system disease may be vertical and
disconjugate, whereas inner ear nystagmus never is. Central nystagmus is
gaze-directed (beats in the direction of gaze) whereas inner ear nystagmus
is direction-fixed (beats in one direction regardless of the direction of
gaze). Central nystagmus is brought out by visual fixation, which supressed
inner ear nystagmus.
- Herr RD, Zun L, Matthews JJ: A directed approach to the dizzy patient. Ann
Emerg Med 1989;18:664-672.
- Froehling DA, Silverstein MD, Mohr DN et al: Does this patient have a serious
form of vertigo? J Am Med Assoc 1994;271;385-388.
- Epley JM: Positional vertigo related to semicircular canalithiasis. Otolaryngol Head Neck Surg 1995;112:154-161.
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Craig Feied, MD
Mark Smith, MD
Jon Handler, MD
Michael Gillam, MD