Assessment of the Vertigo Patient

Please note that the following is a general guideline only. For a full assessment, exclusion of any other underlying cause for your symptoms and an individualised treatment approach, you will need to be seen by a qualified specialist.

Vertigo Definition

Illusion of Rotation due to asymmetry in neural activity between the L and R vestibular systems (Halmagi)

Taking a History

First familiarize your self with the specific features of the above 6 causes of vertigo. These are discussed in the later part. What helps tell these apart are the differences in their onset, length of the symptoms and associated features. 

History taking should be fairly directed ie “ do you feel light headed (not vertigo) or is the roof spinning around (true vertigo)”. How quickly does it come on, in a second or over long period. When it comes on does it last for hours/ or days  with out stopping, or only a few seconds but keeps coming back over days when you move for example?

Following are the main aspects of history

1 Characterize “dizziness”-is it true vertigo not light headedness, True vertigo has a clear sense of motion.

      If true vertigo determine if its central (central vertigo has neurological features) OR... Peripheral vertigo- know the specific features in history that characterizes each type of peripheral vertigo well (conditions discussed in the latter part)

 2  Following are the important aspects of history which helps you differentiate

                    Onset/ predisposing factors 

                    time course,    

                    temporal pattern

3  Associated symptoms (think of DDs) 

                  CNS symptoms-Central vertigo
                  Migraine features
                  Ear symptoms
              
                        

         Examination (the most important ones)

1 Nystagmus

   Central features- Vertical nystagmus, direction changing

   Peripheral features;  horizontal or in BPPV rotatory

2 Head pulsion test-only positive in peripheral vertigo, -ve in central vertigo types

        Get the patient to fixate on an object 2 m in front of him/ her

        keep the head Flexed down by about 3o degrees

        rapid flick-movement of the head to the right then repeat the same to   the left

       if the labyrinth is dysfunctional the eyes will not stay fixed on the object (ie eyes will move with the head and flick back)

       see the following video

       

       

3 Dix Hallpike

If symptoms suggest BPPV do Dix Hallpike to confirm. see the following video

4- Romberg

Balance depends on a tripod

         A the input from the eyes, 
         B the proprioceptors of feet and 
         C tone by the vestibular spinal tracts

stand pt with feed together/ or on cushions (proprioceptors are removed)

ask the pt to close the eyes- visual input is removed (ensure you are ready to catch them)

now the patient relies on their vestibular tone alone- if one side is affected they will sway to that side

note a cerebellar tumor will also have a positive Romberg, however with other central signs as follows

Look for central signs-

- Finger-nose test (dysmetria past-pointing, intention tremor) 

- Ataxia (heel-toe)

- Head Titubation

- Dysarthria

- Otological

- Neurological

- Visual

- Autonomic

        -Other cranial nerves affected

Vertigo Main Conditions

Vestibular Neuronitis

History

Onset: within minutes to hours) onset of severe, 

Time course:  24 hrs or more prolonged rotatory vertigo, nausea, and postural imbalance.

No Hearing Loss (helps differentiate from labyrinthitis)

NO central features

Examination

Peripheral vestibular signs
    Horizontal spontaneous nystagmus

    Head pulsion test is positive (indicates it is NOT a central process)

    Romberg positive to affected side 

No other neurological findings
NO evidence of a central vestibular lesion- no other neurological findings
No hearing loss

Treatment

Supportive

Rx-Steroids

Labyrinthitis

History
Onset:Over hours

Time course: Goes on for a day or more-then slowly subsides

Other: patient is very unwell-vomiting severely, and severe vertigo

          Sensory hearing loss in the affected ear (different from V neuronitis)

Examination

Peripheral signs i.e.
    Nystagmus- horizontal

    head pulsion positive

    Romberg positive- falls to affected side

also may have a middle ear infection

Sensory neural hearing loss

Rx

short course of vestibular sup presents i.e. Diazepam and Stemetil/ steroids

Stop after about 2 days- allow compensation

if middle ear infection- antibiotics

Meniere's Disease

Over diagnosed (vestibular Migraine)

History

Onset:Vertigo only hours, pt may feel unwell for days

Has associated features ; Aural fullness, Rumbling tinnitus , Hearing loss and vertigo

Examination

Peripheral vestibular symptoms as above ie

     Nystagmus- horizontal

     head pulsion positive

     Romberg positive- falls to affected side

BPPV

History

Very common condition

Onset-Short duration vertigo (seconds), with head movement, rolling in bed

Time course: Patient may call it days- as short duration episodes vertigo keeps  over many days- need to specifically ask this

Movement brings it on i.e. turning in bed- wakes up with vertigo, or turning the head

Examination

Positive Dixhallpike test to the affected ear (see the above clip)

Treatment

Epley manoeuvre (not medical treatment)

Vestibular Migraine (very common)

Usually comes on over minutes to hours

Usually lasts over a day

Has other migraine features i.e.

      Photophobia, Phonophobia

      may have an aura

      May have a headache not always

      responds to migraine medications

      can have other neurology i.e. ataxia, tinnitus, other cranial nerve/ neurology