Vertigo in ED
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April 3, 2021
Vertigo is not always labyrinthitis!! There are some potentially serious conditions to think about. Your main question should be is it peripheral [good] or central [bad]?
1. Any features that mandate imaging?
- Neurology deficit
- Significant headache
- Neck pain
- Unable to stand or walk
- Spontaneous vertical nystagmus (i.e. not while doing dix-hallpike)
2. History
- Short episodes <2 min brought on by movement, no spontaneous nystagmus (i.e. only on move)
- BPPV > Dix-Hallpike
- Dizzy for Hours
- Vestibular neuritis vs central > HINTSplus exam (you can only use HINTS if patient is dizzy and has nystagmus)
| Indicator | Peripheral | Central |
|---|---|---|
| Onset | Sudden | Insidious |
| Course | Paroxysmal | Continuous |
| Intensity | Maximum initial | Mild |
| Duration | Min-Hrs | Days-Weeks |
| Vertical Nystagmus | No | Yes |
| Affect of Movement | Significant | Mild-None |
| Tinnitus/Deafness | Common | Rare |
| Other Neurology | Absent | Present |
| Walking | Able | Falls, V. unstable |
| HINTS Exam | All Peripheral | Any Central |
Think about the HINTS exam, its particularly good at identifying posterior strokes (however the patient needs to feel dizzy at reg time of the test)
Causes
| Cause | Duration | Auditory | Periph/Central |
|---|---|---|---|
| BPPV | Seconds | No | Peripheral |
| Vest. Neuritis | Days | No | Peripheral |
| Meniere’s | Hours | Yes | Peripheral |
| Perilymphatic fistula | seconds | Yes | Peripheral |
| Labyrinthitis | Days | Yes | Peripheral |
| Acoustic neuroma | Months | Yes | Peripheral |
| TIA | <24hr | No | Central |
| Stroke | Days | No | Central |
| Migraine (Vest.) | Hours | No | Central |
Vestibular migraine
- One to think about if patient presents without nystagmus – patient should state:
- Recurrent (at least 5 episodes)
- Lasts unto 72hrs
- Has a temporal relationship to migraine symptoms (this may be aura symptoms not headache) at least 50% of the time
- Apparently 2.5% population get this, most un/miss-diagnosed, metacloprimide can help
HINTS Exam – video link
- Head Impulse test
- Rapid passive rotation of head while patient fixes on your nose
- Fixes on nose (central/normal)
- Eyes Correct (periph)
- Nystagmus
- Bilat/Vertical (central)
- Horiz. Unilat (periph)
- Test of Skew
- Repeated cover test of eyes while fixed on nose.
- Eyes move (central)
- Eyes steady (periph)
HINTS Result
- ANY Central features would indicate a central vertigo
- Caution – Only valid if patient dizzy at time. As head impulse test will be normal(i.e score as central) if not dizzy.
- Accuracy – More sensitive than MRI. Sensitivity 96-100% Specificity 85-98%
Treatment
- Medication
- Prochloperazine PO 5mg TDS
- Prochloperazine injection 12.5mg IM
- Betahistine 16mg tds (most effective in Meniere’s)
- Habituation
- Identified dizziness-provoking movements
- Repeat them: five times in a row and twice a day
- Helps to achieve vestibular compensation.
- Follow-Up
- Peripheral – GP/ENT clinic
- Central – Admission or TIA clinic after discussion with stroke team (Most will require imaging from ED)
- DVLA – sudden onset dizziness
Video Guides:
Posterior canal BPPV – Dix-Hallpike and Epley manoeuvre
Horizontal canal BPPV sounds similar to posterior canal (D-H+eply) but tends severe when moves head when upright – tests and how to treat different
PDF:vertigo
DVLA – sudden onset dizziness