Table of Contents
Overview #
Definition
Abnormal sensation of movement, typically referring to a spinning sensation perceived as self-motion or motion of environment.
Key points
- Need to distinguish from other forms of dizziness – presyncope (“faint”), disequilibrium (“imbalance”) and lightheadedness (vague, “woozy”, “foggy”)
- Need to determine whether the vertigo is due to a central (red flag, e.g. stroke) or peripheral (more common) cause
Triage #
Patients with acute vestibular syndrome (acute vertigo, associated with nausea/vomiting, nystagmus and gait unsteadiness) require urgent exclusion of posterior circulation stroke.
Causes #
- Peripheral – vestibular labyrinth, semicircular canals or vestibular nerve
- Acoustic neuroma
- Labyrinthitis – viral, bacterial
- Benign paroxysmal positional vertigo (BPPV)
- Vestibular neuronitis
- Meniere’s disease
- Ototoxicity – aminoglycosides, frusemide, aspirin, quinine
- Central – cerebral cortex, cerebellum or brainstem
- Stroke – ischaemic, haemorrhagic
- Brain tumour
- Multiple sclerosis
- CNS infection – encephalitis, abscess or meningitis
- Mixed
- Vestibular migraine
Clinical features #
Key points
- Central vertigo in isolation is extremely rare
- HINTS exam may be used to exclude stroke in patients with active vertigo – A normal head impulse, direction-changing nystagmus and skew deviation is 100% sensitive and 96% specific for stroke, when performed by a trained practitioner (1)
- Vestibular neuronitis may be clinically diagnosed in patients with acute sustained vestibular syndrome, with peripheral features on HINTS exam but no other neurological signs or hearing loss (2)(3)
- Dix-Hallpike test is used to diagnose BPPV if suspected in the history, with a sensitivity of 79.3% and specificity of 75.0% (4) It is typically only performed when someone’s symptoms have resolved (as opposed to the HINTS exam).
History (5)
| Central features | Peripheral features |
| SustainedCNS symptoms (stroke), associated focal neurology such as diplopia, dysphagia {call out box} | Intermittent (BPPV, Meniere’s) or sustained (vestibular neuronitis)SevereAggravated by posturePreceded by movement (BPPV)Viral prodrome (vestibular neuronitis, viral labyrinthitis)Nausea/vomiting, diaphoresisDeafness and tinnitus (labyrinthitis, Meniere’s, acoustic neuroma, ototoxicity) |
| Symptoms of posterior circulation strokeAltered conscious stateDiplopiaDysarthriaDysphoniaImbalanceVisual disturbanceWeakness (unilateral or bilateral)Sensory loss (unilateral or bilateral) |
Examination
- HINTS examination – Performed when the patient is symptomatic at the time of the exam. Used to exclude central causes if the history is suggestive of peripheral vertigo (not useful in positional transient vertigo, consider Dix-Hallpike test instead)
| Head impulse (6) Steps:Ask the patient to focus on your noseRapidly turn the patient’s head 20 degrees to each side Link to video: https://www.youtube.com/watch?v=DrA4ERU2aG8 Interpretation:Normally, the patient’s eyes would stay fixed to your nose (may also occur in central vertigo)In peripheral vertigo, the patient’s eyes would move with their head, then readjust to look at your nose again (catch-up saccades) Adapted from Geeky Medics: Hohnen H. The Head Impulse, Nystagmus, Test of Skew (HINTS) Examination | Vertigo | Geeky Medics [Internet]. Geeky Medics. 2021 [cited 2 September 2021]. Available from: https://geekymedics.com/the-head-impulse-nystagmus-test-of-skew-hints-examination/ |
| Nystagmus (6) Steps:Ask the patient to look straight ahead, then up, down, left and right without focusing on an objectAsk the patient to focus on your finger and repeat the movements (may also assess diplopia) Interpretation (tricky, but there are general rules):In peripheral vertigo, the eyes usually beat in a consistent direction horizontally, regardless of the direction of gaze (unidirectional horizontal nystagmus)In central vertigo, the direction of nystagmus may change depending on the direction of gaze (bidirectional nystagmus). Note however that very mild bidirectional nystagmus, especially if non-sustained, can represent physiological nystagmus and is benign.Vertical nystagmus is almost always associated with central causes (and rarely with drug toxicity)Visual fixation may suppress nystagmus in peripheral causes, but not in central causesNote that mild nystagmus may occur physiologically at the extremes of gaze Adapted from Geeky Medics: Hohnen H. The Head Impulse, Nystagmus, Test of Skew (HINTS) Examination | Vertigo | Geeky Medics [Internet]. Geeky Medics. 2021 [cited 2 September 2021]. Available from: https://geekymedics.com/the-head-impulse-nystagmus-test-of-skew-hints-examination/ |
- Test of Skew {call out box}
| Call out box: Test of skew (6) Steps:Ask the patient to focus on your noseCover one of the patient’s eyes, then quickly move your hand to the other eyeCheck the uncovered eye for misalignment and corrective movements – positive testRepeat for the other eye Link to video: https://www.youtube.com/watch?v=Ep2dxfIREtQ Interpretation:A positive test of skew suggests a central cause Adapted from Geeky Medics: Hohnen H. The Head Impulse, Nystagmus, Test of Skew (HINTS) Examination | Vertigo | Geeky Medics [Internet]. Geeky Medics. 2021 [cited 2 September 2021]. Available from: https://geekymedics.com/the-head-impulse-nystagmus-test-of-skew-hints-examination/ |
- Dix-Hallpike test {call out box} – Performed if BPPV is suspected in the history (e.g. brief intermittent vertigo), after the symptoms have resolved
| Call out box: Dix-Hallpike test (7) Steps:Ask the patient to sit upright and stand behind themTurn the patient’s head 45 degrees to one sideMove the patient to a supine position and hang their head over the bed 30 degrees below the horizontal planeCheck for nystagmus (wait for 30 seconds)Repeat on the other side Link to video: https://www.youtube.com/watch?v=D6qEdlFVxig Interpretation:A positive test is diagnostic for BPPV if supported by historySensitivity of 79.3% (64.6-94.1) and specificity of 75.0% (32.6-100) (4) Adapted from Geeky Medics: Potter L. Dix-Hallpike Test and Epley Manoeuvre – OSCE guide | Geeky Medics [Internet]. Geeky Medics. 2020 [cited 2 September 2021]. Available from: https://geekymedics.com/dix-hallpike-and-epley-manoeuvres-osce-guide/ |
- Neurological exam – focal neurology in central causes
- Carotid bruits
Investigations #
Initial investigations
| Investigation | Significance |
| FBE | CNS infection |
| Glucose | Hypoglycaemia as a cause of “dizziness” |
| ECG | Embolic stroke due to AF or atrial flutter |
Further investigations
| Investigation | Indication |
| CT Brain + COW (arch to vertex) | Suspected stroke – plain CT to exclude haemorrhage, angiogram for ischaemic stroke or vertebral artery dissection |
| MRI brain (DWI or full sequence) | Suspected stroke, CNS lesion, acoustic neuroma |
Management – Central vertigo #
- Consider escalation and referral if central cause cannot be excluded
- Call a code stroke if it is suspected – see “Stroke” {link to chapter on stroke}
- Arrange urgent neuroimaging
Management – Peripheral vertigo #
- Consider escalation and referral for red flags:
- Acute hearing loss, suspected bacterial labyrinthitis – Discuss with ENT
- Temporary symptom management for acute vertigo (8)
| First line | Prochlorperazine 5 to 10 mg PO 6- to 8-hourly for up to 2 daysOR Promethazine 25 to 50 mg PO 8- to 12-hourly for up to 2 days (maximum daily dose 100 mg) |
| Second line | Diazepam 5 mg PO TDS for up to 2 daysOR Ondansetron 4 to 8 mg orally BD or TDS for up to 2 days |
| If vomiting | Prochlorperazine 12.5 mg IM stat, followed in 6 hours by 5 to 10 mg PO, as a single dose if neededOR Promethazine 10 to 25 mg IM or by slow IV infusion, then 10 to 25 mg PO or IM or by slow IV infusion, 8- to 12-hourlyOR Ondansetron 4 to 8 mg IM or by slow IV injection, 8- to 12-hourly |
- Treat underlying cause (discuss with senior clinician) (2)
| BPPV | Epley manoeuvre |
| Vestibular neuritis | Prednisolone 1 mg/kg (up to 75 mg) PO, daily in the morning for 5 days, then taper dose over 15 days and stop |
| Call out box: Epley manoeuvre (7) Steps:Ask the patient to lie flat, with their head turned to the side and hanging over the bed (continued from Dix-Hallpike test)Turn the patient’s head to the other side and maintain this position for 30 secondsAsk the patient to roll toward the direction of the head turn, so that they can look directly to the floor. This is maintained for 30-60 secondsSit the patient up whilst maintaining the head rotationAfter the patient is upright, turn the head back to the midline so that the patient is facing downwards. Maintain for 30 seconds.Repeat 2-3 times as required Link to video: https://www.youtube.com/watch?v=D6qEdlFVxig Adapted from Geeky Medics: Potter L. Dix-Hallpike Test and Epley Manoeuvre – OSCE guide | Geeky Medics [Internet]. Geeky Medics. 2020 [cited 2 September 2021]. Available from: https://geekymedics.com/dix-hallpike-and-epley-manoeuvres-osce-guide/ |
References #
1. Kattah J, Talkad A, Wang D, Hsieh Y, Newman-Toker D. HINTS to Diagnose Stroke in the Acute Vestibular Syndrome. Stroke. 2009;40(11):3504-3510.
2. Vestibular neuritis [Internet]. eTG Complete. 2017 [cited 2 September 2021]. Available from: https://www.tg.org.au
3. Furman J. UpToDate [Internet]. Uptodate.com. 2021 [cited 2 September 2021]. Available from: https://www.uptodate.com/contents/vestibular-neuritis-and-labyrinthitis
4. Halker R, Barrs D, Wellik K, Wingerchuk D, Demaerschalk B. Establishing a Diagnosis of Benign Paroxysmal Positional Vertigo Through the Dix-Hallpike and Side-Lying Maneuvers. The Neurologist. 2008;14(3):201-204.
5. Hayes J. Vertigo. In: Hayes J. Title: Northern Hospital guidelines. Melbourne: Northern Hospital; 2018.
6. Hohnen H. The Head Impulse, Nystagmus, Test of Skew (HINTS) Examination | Vertigo | Geeky Medics [Internet]. Geeky Medics. 2021 [cited 2 September 2021]. Available from: https://geekymedics.com/the-head-impulse-nystagmus-test-of-skew-hints-examination/
7. Potter L. Dix-Hallpike Test and Epley Manoeuvre – OSCE guide | Geeky Medics [Internet]. Geeky Medics. 2020 [cited 2 September 2021]. Available from: https://geekymedics.com/dix-hallpike-and-epley-manoeuvres-osce-guide/
8. Symptomatic treatment of acute vertigo [Internet]. eTG Complete. 2017 [cited 29 August 2021]. Available from: https://www.tg.org.au
Contributors
Reviewing Consultant/Senior Registrar
Dr Cheng Xie
Dr Arthur Thevathasan
