Vertigo

Vertigo is a topic covered in the 5-Minute Clinical Consult.

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Basics

Description

  • A symptom, not a disease process. Causes can be peripheral or central, benign, or life-threatening. Cause determines treatment.
  • May be described as a sensation of movement (“room spinning”) when no movement is actually occurring
  • However, do not rely on symptom quality—often unreliable. Focus on timing and triggers (1).
  • System(s) affected: nervous, cardiovascular, psych
  • Synonym(s): dizziness

Epidemiology

Incidence
  • Vertigo/dizziness accounts for >4 million ED visits a year in United States, of which 80–85% have no serious underlying condition (2).
  • Predominant sex: female = male; women are 3 times more likely to experience vertiginous migraine (1).
Geriatric Considerations
  • Keep a higher index of suspicion for CVD, arrhythmias, and orthostatic hypotension.
  • BPPV is more common in ages 50 to 70 years (1), an important risk factor for falls but is often undiagnosed.
  • Medications are implicated almost 1/4 of the time (1).

Prevalence
  • Ranges from 5% to 10% within the general population
  • Lifetime prevalence for BPPV is 2.4%.

Etiology and Pathophysiology

  • Dysfunction of the rotational velocity sensors of the inner ear results in asymmetric central processing; combination of sensory disturbance of motion and malfunction of the central vestibular apparatus
  • Peripheral causes: acute vestibular neuritis, BPPV (posterior canal 85–95%, lateral canal 5–15%), Ménière disease, otosclerosis, acute labyrinthitis, cholesteatoma, perilymphatic fistula, superior canal dehiscence syndrome, motion sickness (1). BPPV, vestibular neuritis, and Ménière disease account for majority of peripheral causes (1).
  • Central causes: cerebellar tumor, stroke, migraine, vestibular ischemia (1,2)
  • Drug causes: psychotropic agents, anticonvulsants, aspirin, aminoglycosides, furosemide (diuretics), amiodarone, α-/β-blockers, nitrates, urologic medications, muscle relaxants, phosphodiesterase inhibitors (sildenafil), excessive insulin, ethanol, quinine, cocaine
  • Other causes: orthostasis, arrhythmia, psychological

Genetics
Family history of CVD/migraines may indicate higher risk of central causes.

Risk Factors

  • History of migraines
  • History of CVD/risk factors for CVD
  • Use of ototoxic medications
  • Trauma/barotrauma
  • Perilymphatic fistula
  • Heavy weight-bearing
  • Psychosocial stress/depression
  • Exposure to toxins

General Prevention

If due to motion sickness, consider pretreatment with anticholinergics, such as scopolamine.

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