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.
• System(s) affected: nervous, cardiovascular, psych
• Synonym(s): dizziness

Epidemiology

• Vertigo/dizziness accounts for >4 million ED visits a year in United States, of which 80–85% have no serious underlying condition (1).
• Predominant sex: female = male; women are 3 times more likely to experience vertiginous migraine (2).

Geriatric Considerations

• Keep a higher index of suspicion for CVD, arrhythmias, and orthostatic hypotension.
• Benign Paroxysmal Positional (BPPV) is more common in ages 50 to 70 years (2), an important risk factor for falls but is often undiagnosed.
• Medications are implicated almost 1/4 of the time (2).

• 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 (2). BPPV, vestibular neuritis, and Ménière disease account for majority of peripheral causes (2).
• 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.