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Vertigo

Dizziness is common in primary care affecting 21% of the population (BJGP 1998;48:1131). It often starts with an
element of vestibular imbalance and then becomes more complicated, with tension and anxiety muddying the
water. These patients often present from time to time to a new clinician with an acute episode, but closer
questioning elicits a chronic recurring–relapsing condition. These patients are traditionally difficult to manage.

Differential diagnosis
In an editorial in the BMJ, Charing Cross Hospital neurologists Kaski and Bronstein make a plea to avoid diagnosing labyrinthitis in
every case of vertigo (BMJ 2012;345:e5809).

They remind us the terms are not synonymous: vertigo is simply a term for an illusion of movement; labyrinthitis (or, more correctly,
vestibular neuritis) is actually quite rare, with an incidence of 3.5/100 000/y. In one study, only 15% of patients referred to a neuro-
otology service with vestibular neuritis had a correct diagnosis; most of the others had benign paroxysmal positional vertigo (BPPV)
or vestibular migraine.

This seems rarer than I would expect! They are considering the hospital population they see in outpatients, where we might expect
labyrinthitis to be rarer as it is usually self-limiting. Nevertheless, it is useful to ensure we are confident in how to assess vertigo.

So, how do we get the diagnosis right?

First, be sure it is vertigo. Is there an illusion of movement? If not, consider other causes of ‘dizziness’ or instability (postural
hypotension, pre-syncope, peripheral neuropathy, etc.).

Differential diagnosis Features

BPPV Typically starts on getting out of bed/turning over.
Vertigo triggered by movement.
Settles with stillness/avoiding movement that triggers it.
Test for it with Hallpike’s manoeuvre that will trigger an
attack.
90% of cases involve posterior semi-circular canals.
Epley manoeuvre or Brandt-Daroff exercises are options
for treatment.
Vestibular migraine Similar to BPPV history but without the association with
movement.
Stress can induce.
Hallpike’s manoeuvre will not trigger an attack.
Headache may be before or after (or during) the attack,
and may not be prominent as it is in other forms of
migraine.
Evidence is limited for disease-specific treatments as no
intervention trials have been conducted, but expert
consensus is to try conventional migraine treatments
(BMJ 2017;358:j3727).
Vestibular neuritis (labyrinthitis) Sudden-onset, continuous rotational vertigo.
Nausea and vomiting usually present.
Cannot get any relief in any position.
Usually a home visit request!
Can last several days. Usually stay in bed – miserable!
Examination will show unilateral nystagmus and a loss of
the vestibulo-ocular reflex.
Do a head thrust test (see below).
Use vestibular sedatives/antiemetics in the acute phase,
and vestibular rehabilitation if vertigo persists after.

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Ménière’s disease Presents with a typical cluster of symptoms. Attacks last at least
20min and no more than 24h:
Tinnitus.
Vertigo.
Fluctuating sensorineural hearing loss at low
frequencies.
Sensation of ear fullness.
Fewer than 10% will experience drop-attacks – sudden
falls with the sensation of being pushed, with no loss of
consciousness and an immediate ability to resume normal
activities.
These symptoms may not all occur at once, and clinical
findings are normal between attacks. There is a separate
article on Vertigo: Ménière’s disease and betahistine.

Cerebellar stroke May present similarly to vestibulo-neuronitis but may have

even more severe imbalance.
Usually unable to stand.
May experience hearing loss, other cranial nerve deficits
and upgoing plantars.
Beware: nystagmus may be absent or vertical.

The head thrust test

Patients with vestibular neuritis will have lost their vestibulo-ocular reflex on one side. This is the reflex that allows you to fix
your gaze on a point even if your head is moving. This reflex can be tested with the head thrust test:

Explain to the patient what you are about to do!

Ask the patient to fix their eyes on your nose.

Turn their head rapidly to one side (you only need to move it by about 10–20°, but speed is important).

Normally, individuals will remain looking at your nose.

If the vestibulo-ocular reflex fails (as it does in vestibular neuritis), the patient’s eyes will move as their head moves, and then jump
back to fix on your nose.

There is a link to a video demonstrating this in the Useful websites box.

In other respects, examination of patients with vestibular neuritis will be normal, and they are unlikely to have a headache or
deafness. This condition rarely recurs, and you should reconsider your diagnosis if it does.

Remember that some posterior circulation strokes can also cause a positive head thrust test – look closely for other features of a
posterior circulation stroke (outlined in the article on strokes).

The Epley manoeuvre

Does the Epley manoeuvre work for acute vertigo symptoms?

A small, Spanish, primary care-based trial randomised 134 patients with benign positional paroxysmal vertigo (BPPV) to undergo
either an Epley manoeuvre or a sham procedure (BJGP 2019; 69 (678):e52). All patients were also prescribed betahistine (not
standard practice in the UK!). The intervention group reported lower severity of vertigo symptoms at 1 week, but only in those
patients who had an initially positive Dix-Hallpike test with nystagmus.

The trial did not report the results of the patients with subjective BPPV symptoms but a negative Dix-Hallpike test, and several
patients were excluded from the trial after randomisation had taken place. Although promising, the small sample size and the fact
that all patients also took betahistine make these results difficult to extrapolate to our UK primary care population. We have included
a link to the Epley manoeuvre in the online resources at the bottom of this article.

Brandt-Daroff exercises

NICE CKS on BBPV (accessed May 2019) advise a trial of Brandt-Daroff exercises if the Epley manoeuvre is not successful or
cannot be performed. We have included a link to these in the online resources section below.

Chronic vertigo
Epidemiology and aetiology
Chronic vertigo is usually defined as vertigo symptoms lasting for more than 1m despite treating the underlying cause (assuming we
got this correct in the first place!). All conditions that can cause acute vertigo have a fairly high conversion rate to chronic (persistent)

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vertigo. For example:

Vestibular neuronitis: 30–40% still experience vertigo symptoms at 6m.

BPPV: 50% of patients will have experienced episodes of recurrence over 3–5y from diagnosis.

This may become a recurrent or continuous vertigo sensation. The vestibular system has a repair mechanism called ‘vestibular
compensation’. The rate at which this occurs varies between individuals. If it fails to occur, it contributes to persistent vertigo.

Management

Historically, there have been high rates of prescribing of vestibular sedatives, e.g. prochlorperazine and betahistine used in an off-
licence fashion. A BMJ ‘Change’ article made a strong plea to use vestibular rehabilitation exercises rather than drugs to manage
these patients (BMJ 2017;358:j3727).

This was evidenced in two Cochrane Reviews (Cochrane 2016;CD010696 and 2015;CD005397):

Patients undergoing vestibular rehabilitation were 3× more likely to experience meaningful improvement.
There were no adverse events.
By contrast, off-licence betahistine use in an undifferentiated chronic vertigo population had very marginal benefits compared
with placebo.

Despite this, a survey of Dutch and UK GPs indicates that only about 7% recommend vestibular rehabilitation exercises.

Stopping off-licence prescribing of betahistine for this indication would save the NHS £4 million pounds annually.

Accessing vestibular rehabilitation

The BMJ article is not so helpful at this! It reports that the main barrier to GPs offering this is that they don’t know how to do it… and
then fails to enlighten us!

It suggests we stop all their drugs and then offer ‘books or internet-based interventions’, or refer to physiotherapists or audiologists.
Some of this may depend on local service provision.

We have identified some useful resources for patients, and include links to these in the Useful websites section below.

Let’s also consider an older primary care study where patients were offered a self-help booklet (BMJ 2012;344:e2237):

35 UK surgeries used the records to select patients with chronic dizziness. They were identified because they were taking long-term
vestibular sedatives or had active codes for dizziness or vertigo. A pre-treatment questionnaire was used and patients were
excluded if they no longer had dizziness or if rapid head movements did not aggravate their dizziness.

The 337 patients were then randomised to three options:

Normal treatment: no change from their current treatment.

Offered a booklet explaining both the rehabilitation exercises they should carry out for 12w and also some CBT techniques.
Offered the booklet as above and, in addition, have three brief phone calls from audiologists for support.

Note that this booklet is available from the Ménière’s Society and there is a link below.

Results
Results were collated by self-completion questionnaires at 12 and 52w.
Adherence to the exercises was 34% in the booklet-only group and 44% in those with telephone support as well.
At 12w, there was no difference between the three groups in terms of vertigo scores or other measures such as HADs scores.
At 52w, those who had been given the booklet (whether they had phone support or not) had improved vertigo scores, fewer
symptoms related to dizziness and reduced handicaps related to dizziness.

The beauty of this study was that it was truly primary care-based with few exclusions, yet still seemed to show a moderate benefit in
the long term in this difficult-to-treat group of patients.

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Vertigo
Differential diagnosis
Not all acute dizziness is labyrinthitis: indeed, it is rarely the cause.
Think BPPV and migraine.
Consider rarer causes: Ménière’s and cerebellar stroke.
Chronic dizziness and rehabilitation exercises
Chronic dizziness is common in the population. It may be complicated by tension and
anxiety.
There is no role for long-term vestibular sedatives or betahistine.
There is better evidence for vestibular rehabilitation, and even a booklet-directed
intervention appears modestly effective.

How many patients do you have on vestibular sedatives? How many have had a review and
trial of rehabilitation exercises?

The booklets used in this study are available from The Ménière’s Society:
www.menieres.org.uk/files/pdfs/balance-retraining-2012.pdf
www.menieres.org.uk/files/pdfs/controlling-your-symptoms.pdf
There is also an online participation version that is free to access:
https://balance.lifeguidehealth.org/player/play/balance
The head thrust test can be seen at: www.youtube.com/watch?v=CZXDNLLGG8k
The Epley manoeuvre can be seen at: https://www.youtube.com/watch?v=jBzID5nVQjk
Brandt-Daroff exercises: https://www.wsh.nhs.uk/CMS-Documents/Patient-leaflets/ENT/6331-
1-Brandt-Daroff-Exercises.pdf

We make every effort to ensure the information in these articles is accurate and correct at the date of publication, but it is of necessity of a brief and general nature, and
this should not replace your own good clinical judgement, or be regarded as a substitute for taking professional advice in appropriate circumstances. In particular check
drug doses, side-effects and interactions with the British National Formulary. Save insofar as any such liability cannot be excluded at law, we do not accept any liability
for loss of any type caused by reliance on the information in these articles.

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