vertigo
VERTIGO

Vertigo is having a sensation of spinning of either the surrounding or within oneself but physical movement does not exist.

It may be secondary to different causes that may be determined by numerous factors eg timing and duration, aggravating conditions or associated symptoms.
Central vertigo originates from the central nervous system (brainstem or cerebellum). It is uncommon but more serious and should be ruled out immediately.
Peripheral vertigo originates from the labyrinth or vestibular nerve.

Pharmacotherapy

Benign Paroxysmal Positional Vertigo

  • Medications are not routinely given in BPPV other than in patients w/ severe vegetative symptoms such as nausea or vomiting

Meniere’s disease

  • Antiemetic medications (eg Promethazine, Prochlorperazine) for nausea & vomiting control
  • Diuretics (combination of Hydrochlorothiazide & Triamterene) helps lower endolymphatic pressure
  • Betahistine & labyrinth ablation therapies w/ intratympanic Gentamicin also aids in lowering endolymphatic pressure
  • Intratympanic glucocorticoids showed some benefit in patients w/ intractable Meniere’s disease
  • Vestibular blocking/suppressant agents (eg Meclizine, Dimenhydrinate, Diazepam, Glycopyrrolate, Lorazepam) to reduce the spinning sensation
  • Antistamines w/ calcium channel blocking activity, eg Cinnarizine, may be effective in patients w/ “vestibular Meniere’s” due to the high prevalence of migraine in these patients
    • A recent study supported Cinnarizine’s proactive role in the prevention of vertiginous spells particularly in Meniere’s disease patients w/ migraine
      • A retrospective study also suggested the safety & efficacy of Cinnarizine in decreasing both headache & vertigo components in patients w/ migrainous vertigo or migraine w/ brainstem aura associated w/ vertigo

Acute vestibular dysfunction

  • Antiemetic medications (eg Prochlorperazine) for nausea & vomiting control
  • Methylprednisolone as acute treatment to improve functional vestibular recovery
  • Vestibular blocking/suppressant agents (eg Dimenhydrinate) to reduce the spinning sensation
  • Acetyl-DL-leucine has been used in clinical practice to reduce imbalance & autonomic manifestations associated w/ acute vertigo crises
    • Commonly used for cerebellar disequilibrium & nystagmus

Non-Pharmacological Therapy

  • Vertigo management is usually comprised of symptomatic and non-pharmacological therapy
  • Acute & severe episodes of vertigo, regardless of the underlying cause, will usually settle 24-48 hrs due to the effect of brainstem compensation

Benign Paroxysmal Positional Vertigo (BPPV)

Observation

  • Initial therapy for BPPV
  • “Watchful waiting” or postponing PRMs &/or vestibular rehabilitation to see if the symptoms of BPPV will take its natural spontaneous course of improvement
  • Positions or activities that would induce vertigo attack should be avoided by the patient during the course of observation

Particle Repositioning Maneuvers (PRMs)

  • Different maneuvers that can be done to move the canaliths from the semicircular canal to the vestibule from which they are absorbed
  • Can consistently eliminate vertigo due to BPPV, improve quality of life & reduce risks of falling
  • Canalith repositioning procedure (CRP or Epley maneuver)
    • An effective & safe therapy that should be offered to patients of all ages w/ posterior semicircular canal BPPV
    • Maneuver that moves the canaliths from the posterior semicircular canal to the vestibule, thus relieving the stimulus from the semicircular canal that have been producing the BPPV
    • Nausea, occasional vomiting &/or sense of falling may arise during the procedure
    • Provides a short-term relief of symptoms of posterior canal BPPV
    • Success of single treatment is 50-90% while repeated CRPs over time approaches 100% success rate
    • CRP should not be done in patients w/ severe carotid stenosis, unstable heart disease, severe neck pathology (eg cervical spondylosis w/ myelopathy or advanced rheumatoid arthritis)
  • Semont maneuver
    • Insufficient evidence of effectiveness
  • Gufoni maneuver
    • Effective treatment for horizontal canal BPPV
  • Forced prolonged positioning
    • An option for refractory horizontal canal BPPV but w/ high remission rates
    • This position allows the otoconia to fall out of the horizontal canal
  • Roll maneuver
    • Lempert maneuver or barbecue roll maneuver
    • Moderately effective & widely used treatment for lateral canal BPPV
  • Vannuchi-Asprella liberatory maneuver
    • May be effective for lateral canal BPPV but there are limited clinical studies regarding use

Vestibular Rehabilitation

  • Physical therapy composed of habituation exercises & home repositioning exercises performed by the patient for the treatment of BPPV w/ or w/o direct clinician supervision
  • As effective as PRMs in bringing symptom resolution in posterior canal BPPV
  • Habituation exercise
    • Start w/ simple head movements, performed in sitting or supine position
    • Then progress to complex activities, including walking on slopes & steps w/ eyes open & closed, & sports activities requiring eye-hand coordination
    • These exercises will cause fatigue in the vestibular response & will force the CNS to compensate by habituation to the stimulus
  • Home repositioning exercise/Brandt-Daroff Maneuver
    • The patient starts in a sitting position & moves quickly to the right-side lying position w/ the head rotated 45 degrees & facing upward
    • The position is maintained for 30 seconds after the vertigo stops
    • The patient then moves rapidly to a left-side lying position, w/ the head rotated 45 degrees & facing upwardThis exercise will promote loosening & ultimately dispersion of debris toward the utrical cavity

Meniere’s Disease

Lifestyle Modification

  • To lower endolymphatic pressure:
    • Observe low salt diet (<1-2 g/day)
    • Avoid intake of caffeinated beverages (eg cola, coffee or tea)
    • Limit alcohol intake to 1 drink/day
    • Avoid smoking

Rehabilitation

  • Vestibular rehabilitation exercises train the brain to use alternative visual & proprioceptive cues to maximize balance & CNS compensation for imbalance
  • Hearing aid to the affected ear helps in improving hearing problems

Meniett Device

  • Positive pressure pulse generator
  • A device that applies intermittent positive pressure to the ear canal through a ventilation tube that helps to improve fluid exchange in the inner ear
  • It is being done at home for 5 mins at a time usually 3x/day
  • Initial reports show improvement of symptoms of Meniere’s disease but the device is expensive

Acute Vestibular Dysfunction

Bed Rest

  • Important in the acute phase of vestibulopathy

Vestibular Rehabilitation Exercises

  • For more rapid & complete compensation of vestibular function
  • Shown to speed up recovery & improve disability in patients w/ permanent vestibular injury
Editor's Recommendations
Most Read Articles
01 Jan 2015
Ginkgo biloba has been shown to improve cognitive as well as neuropsychiatric symptoms (NPS) in patients with Alzheimer’s disease (AD) and mixed dementia. During a Schwabe-sponsored symposium last 20 October 2014 held at the University of Malaya in Malaysia, Professor Serge Gauthier of the McGill Centre for Studies in Aging in Quebec, Canada, and Dr Robert Hoerr of the Dr Willmar Schwabe GmbH & Co. KG in Germany, discussed studies that support the safety and efficacy of Ginkgo biloba extract (EGb 761®) in patients with AD and dementia.
26 Aug 2017
Elderly individuals with high levels of serum uric acid may be at an increased risk of dementia, particularly vascular or mixed dementia, a study suggests.
Dr. Joseph Delano Fule Robles, 01 Mar 2017

The tau and Aβ amyloid pathways have emerged as possible novel targets in treating Alzheimer’s disease (AD), according to studies discussed at the recently concluded Hong Kong Pharmacy Conference.