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Vertigo Care Pathway Overview

This pathway has been developed to provide clear guidance to GPs on the management of vertigo in order to support GP assessment and management, and provide guidance on appropriate referral routes.

Vertigo is characterised by disabling episodes of imbalance with hallucination of movement e.g. spinning. In this way it is distinguished from other forms of dizziness.

  • vertigo is caused by peripheral causes in 80% of vertigo cases
  • the most common cause of peripheral vertigo is benign paroxysmal positioning vertigo (BPPV; 25%)
  • labyrinthitis or vestibular neuronitis is a cause of peripheral vertigo in 25% of cases
  • Meniere's disease is a cause of peripheral vertigo in 10% of cases
  • vertigo is caused by central causes in 20% of cases:
  • migraine is increasingly recognized as one of the commonest causes of intermittent vertigo
  • cerebrovascular disease may account for a significant amount of more chronic dizziness (but not true vertigo)
  • central causes of vertigo are more common in the elderly than in younger groups
  • tumours account for less than 1% of the overall population with dizziness (these are predominantly acoustic neuromas)

 

 Please click the relevant flowchart box to be taken directly to textual information.

                          

Red Flags
Cerebrovascular accident (CVA)
Unilateral acute hearing loss
Abnormal neurological symptoms or signs e.g. diplopia, Cranial Nerve (CN) palsies, dysarthria, ataxia etc
New headache
Normal vestibule-ocular reflex on head impulse testing
Vertical nystagmus
Suspected tumour
Differential Diagnosis
  • Presyncope
  • Disequilibrium in the elderly (associated with peripheral neuropathy, eye problems or peripheral vestibular disorders
  • Light-headedness
  • Multiple sclerosis (MS)

Refer to Neurology for further testing only if central vestibular disorders are suspected:

  • cerebrovascular disease
  • tumour
  • multiple sclerosis (MS)

Vertigo tends to feel more unpleasant in peripheral than central vertigo:

  • associated neurological features:
    • rare in peripheral vestibular disorders as opposed to central vestibular dysfunction
  • nystagmus:
    • tends to be unidirectional with peripheral lesions, but may be multidirectional with central lesions
  • examine for:
    • hyper-reflexia
    • speech change
    • papilloedema
    • abnormal eye movements
    • ataxia
Initial Primary Care Assessment

The history is the most important aid to diagnosis

Define the:

  • time course of the vertigo: how long does the disabling sensation last?
  • triggers for vertigo (e.g. change of head position, menstrual cycle)
  • associated neuro-otological symptoms (e.g. hearing loss, tinnitus, aural fullness, headache)

Investigations are often unnecessary, but based on history and clinical findings, consider some or all of the following tests:

  • haematological or biochemical:
  • full blood count (FBC)
  • urea and electrolytes
  • fasting blood sugar
  • serum lipids
  • thyroid function tests
  • serology for syphilis
  • autoimmune profile

  • term used to describe primary endolymphatic hydrops
  • thought to arise from an abnormal homeostasis of inner ear fluids
  • it can only be definitively diagnosed by histopathological analysis of the temporal bone
  • can begin at any age – typically first symptoms occur between age 20-40 years
  • rarely, children may present with Meniere's-like symptoms due to secondary endolymphatic hydrops associated with congenital
  • malformations of the inner ear
  • clinical features of Meniere's disease include the following:
    • vertigo – characteristically rotatory and can be associated with nausea and vomiting, episodes usually lasting 20 minutes to 24 hours.
    • hearing loss is sensorineural, initially affecting the lower pitches
    • fluctuating hearing loss may progress over time, and fluctuates resulting in permanent hearing loss at all frequencies
    • the aura of 'fullness' or pressure in the ear or the side of the head can last from 20 minutes to several hours
    • tinnitus may be associated with auditory distortion and usually gets worse during episodes
  • the clinical course varies among individuals
  • unilateral in most cases – affects both ears eventually in approximately 30% of cases
  • it is a diagnosis of exclusion, since other pathologies such as acoustic neuroma and otosyphilis may present as endolymphatic hydrops (secondary endolymphatic hydrops)
  • most patients can be managed conservatively by medical treatment; however, a small proportion may require surgical intervention

Disabling vertigo usually lasting days and associated with hearing loss:

  • acute labyrinthitis from either bacterial or viral infections is associated with hearing loss
  • labyrinthitis is sometimes associated with bacterial processes such as otitis media or meningitis
  • antibiotics and/or surgical drainage may be required

Disabling vertigo usually lasting days and NOT associated with hearing loss:

  • patients usually complain of abrupt onset of severe, debilitating vertigo with associated unsteadiness, nausea and vomiting
  • patients often describe their vertigo as spinning, which increases with head movement
  • on physical examination spontaneous, unidirectional, horizontal nystagmus is the most important physical finding and fast phase beat away from the side of lesion (acute phase)
  • the patient tends to fall toward the affected side when attempting ambulation or during Romberg tests
  • affected side has either unilaterally impaired or no response to caloric stimulation (though this test is rarely performed in this situation)
  • patients may develop benign paroxysmal postural vertigo (BPPV) later

The following symptoms should be absent:

  • multidirectional, non-fatiguing nystagmus suggesting vertigo of central origin
  • hearing loss
  • other cranial nerve deficits
  • truncal ataxia (suggests cerebellar disease or another central nervous system [CNS] process)
  • inflamed tympanic membrane
  • mastoid tenderness
  • high fever
  • nuchal rigidity

Causes:

  • viral infection of the vestibular nerve and/or labyrinth is believed to be the most common cause of vestibular neuronitis
  • acute localised ischaemia of these structures also may be an important cause

Benign paroxysmal positional vertigo (BPPV) is the most common causes of vertigo, thought to arise from the presence of abnormal dense particles, most likely otoconial debris, in the posterior semi-circular canal (although other semi-circular canals can be affected)

  • characterised by severe, brief paroxysms of rotational vertigo provoked by positional changes usually lasting seconds to minutes.
  • classic posterior canal BPPV is idiopathic in 35% of cases
  • about 15% of patients have a history of relatively minor prior head trauma
  • the remainder is a residual effect of a variety of vestibular pathologies, most commonly Meniere's disease (30%), but also vestibular neuronitis, ear surgery and inner ear ischaemia

Diagnostic test:

  • observing nystagmus during a provoking manoeuvre confirms the diagnosis of BPPV in patients with a typical history
  • Hallpike's positional test provokes dizziness and a typical geotropic upbeat torsional nystagmus is diagnostic of this condition:
    • with the patient sitting, the head is turned 45 degrees to one side
    • the patient is then placed supine rapidly, so that the head hangs over the edge of the bed (it is perfectly acceptable to lie the patient flat without extending their neck particularly if there are concerns about the neck)
    • the patient is kept in this position for at least 30 seconds
    • if no nystagmus occurs, they are then returned to the upright position and observed for another 30 seconds for nystagmus
    • the manoeuvre is repeated with the head turned to the other side
    • nystagmus usually appears with a latency of a few seconds and lasts less than 30 seconds (fatigues)
    • it has a typical trajectory, rotatory, torsional  and geotropic (beating towards the floor)after it stops and the patient sits up, the nystagmus will recur but in the opposite direction
  • diagnosis based on history alone, without Hallpike's test, may miss about a quarter of people with BPPV
  • caution should be exercised while performing the manoeuvre in patients with degenerative disease of the cervical spine
Initial Primary Care Management (1)

For Meniere's disease / Labyrinthitis / Vestibular Neuritis

Prescribing

Drugs to suppress vestibular system

  • chief role of medication is to alleviate symptoms such as vertigo, nausea and vomiting during an acute or transient dizzy episode
  • three general classes of drugs are used to suppress the vestibular system, although their effectiveness has not been reliably assessed:
    • antihistamines, e.g. cinnarizine are generally prescribed for the treatment of vertigo as a result of Meniere's disease - length of administration should be 24 hours
    • phenothiazines, e.g. prochlorperazine are generally prescribed for treatment of vertigo as a result of labyrinthitis - length of administration should be no more than 7 days. Long term prescriptions can prevent vestibular compensation.
  • Avoid use in the long-term as prevents central compensation of vestibular insults – use on an as-required basis only
Initial Primary Care Management (2)

For Benign Paroxysmal Positional Vertigo (BPPV)

Consider Canalith repositioning manoeuvres, including:

These are repetitive sets of manoeuvres (similar to Hallpike manoeuvre), which place the patient sequentially in supine, sitting and semi-supine positions, with the aim of repositioning deposits within the vestibular apparatus, which may be responsible for symptoms:

  • caution should be exercised while performing the manoeuvre in patients with degenerative disease of the cervical spine

Manoeuvres act by dispersion of the canal debris from the posterior semicircular canal into the utricle, where it is inactive:

  • to target the left posterior semicircular canal (PSC):
    • start with patient sitting up at torso length from the end of the bed (so that the head and neck can extend over the end of the bed)
    • lie the patient down while holding the head 45º to the left
    • head is placed over the end of the bed extending the neck between 0°-30° below the horizontal
    • while the head is kept tilted downwards it is rotated 90º to the right
    • head and body are then rotated further to the right so the face is angled 135° below the horizontal (ie looking down to the right with the patient lying on their right shoulder)
    • while head is kept turned right, patient is brought to the sitting position
    • finish with head looking downward, chin down to 20º
  • pause at each position until any induced nystagmus stops, or 30 seconds, keep repeating series until there is no nystagmus at any position
  • reverse procedure for the right PSC (start with head 45º to the right)​
When to Refer

Consider referral to Physiotherapy for Vestibular Rehabilitation (see below)

Consider referral to ENT if:

  • symptoms persist following conservative management

Or

  • further investigations are needed to confirm diagnosis
Secondary Care Management - Physiotherapy

Vestibular rehabilitation

Vestibular rehabilitation is the assessment and management of patients suffering from feelings of dizziness/unsteadiness due to incorrect function of balance organs in the inner ear (vestibular disorder). Often when symptoms of dizziness or unsteadiness have been present for some time poor compensation of the balance system occurs and a graded exercise based treatment is required to improve symptoms.

Vestibular Rehabilitation will help the brain to process information it receives from the body in a new way to help return balance and reduce symptoms.

Vestibular Rehabilitation can help many people with their symptoms but assessment of these symptoms is required to guide patients to perform an individualised exercise programme suited to them. It may be useful for those who have episodic recurrent symptoms or those who are presenting with their first episode of vertigo. A physiotherapist will assess the patients' particular needs and tailor treatment accordingly.

It can involve:

  • Exercise based treatments
  • Psychological support
  • Guidance with relaxation therapies led by Physiotherapist and Hearing Therapists.

Direct referrals can be made to your local Physiotherapy department to see a physiotherapist who works within Vestibular Rehabilitation. Hearing Therapy is a pathway for complex patients e.g. Meniere's, the Physiotherapists and ENT department refer direct to Hearing Therapy. This service is not directly available to GPs.

Patients can choose to access Vestibular Rehabilitation provided by Gloucestershire Hospitals NHS Foundation Trust  at any of the sites listed below, either via GP letter referral  - please email your referral document to ghn-tr.physiotherapy@nhs.net

or 

self-referral using this online self-referral form:

  • Gloucestershire Royal Hospital
  • Cheltenham General Hospital
Secondary Care Management - ENT

In secondary or tertiary care, the following tests may be considered:

  • audio-vestibular:
    • pure tone audiogram
    • auditory brain stem responses
    • electronystagmography
    • posturography
    • caloric test
  • radiological:
    • magnetic resonance image (MRI)
    • computed tomography (CT) scan of temporal bones
    • cervical spine X-ray
    • MRI angiography
    • transcranial Doppler ultrasound                                      

For Meniere’s disease, ablative surgery or medical procedure may be considered:

  • intra-tympanic gentamicin has been shown to abolish the vertigo of Meniere's disease in 80% of those treated and greatly reduces it in 96%; it has become an important treatment for this condition
  • intra-tympanic dexamethasone is advocated by some, but evidence remains incomplete on its effectiveness
  • endolymphatic sac surgery
  • vestibular nerve section/neurectomy
  • labyrinthectomy
Ongoing Care

Following diagnosis a treatment strategy will be devised to control symptoms.

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