What’s in the web for family physicians – management update on vertigo

Wilbert WB Wong 王維斌，Alfred KY Tang 鄧權恩

Vertigo is a distressing presenting symptom common in general practice. Classically, vertigo is a feeling of movement in the environment around the patient. Often patients describe a ‘spinning’ sensation of either their body or their surroundings. Most of the time patient will generally describe the condition as ‘dizziness’.

Dizziness is a non-specific term . It can be categorised into four different subtypes according to symptoms described by the patients: vertigo, presyncope with fainting, light-headedness or disequilibrium with a feeling of unsteadiness or imbalance when standing.

Vertigo can be central or peripheral. The central type refers to a brainstem or cerebellar disorder. The peripheral type is due to disorders of the inner ear or the Vestibulocochlear (VIIIth) cranial nerve.

As a family physician, vertigo is commonly encountered condition and most patients can be managed in outpatient setting. A better understanding of the condition can definitely improve patient care.

Diagnosing the cause of vertigo: a practical approach

To make a diagnosis on the cause of vertigo is often challenging. A detailed history with a systematic approach is most important while evaluating patients with dizziness. This local paper from Hong Kong Medical Journal provides a practical clinical approach in identifying the cause of a vertigo attack.

Causes of vertigo may be otological, central, somatosensory, and visual. While taking history, there are several questions that are of great help to sort out the causes. The first question is “What does the patient mean by dizziness?” This helps to identify the true vertigo or other causes of dizziness.

The second question is, “Is the vertigo central in origin?” Peripheral vertigo is usually sudden in onset and is always made worse by head movement. Central vertigo is more gradual or subacute in onset, and may be persistent.

The third question is, “How long does the vertigo last?” Vertigo lasting for seconds is likely to be Benign Paroxysmal Positional Vertigo. If lasting for minutes, it can be vertebrobasilar insufficiency or transient ischaemic attack. Vertigo of minutes to hours suggests Meniere’s syndrome or migraine. If it continues for hours to days, it points more to acute vestibular failure, like infective labyrinthitis, vestibular neuronitis or ototoxicity. Vertigo that is constant for weeks suggests psychogenic causes or central lesions. Characteristics of some of the common causes of dizziness are summarised in the article. The key to arriving at the diagnosis is to differentiate vertigo from other causes of dizziness and to distinguish central from peripheral causes of vertigo. Appropriate treatment can significantly improve the quality of life in patients suffering from vertigo.

Clinical practice guideline: benign paroxysmal positional vertigo

This is a guideline published by The American Academy of Otolaryngology- Head and Neck Surgery in March 2017. This website harbors the full version of clinical practice guideline on benign paroxysmal positional vertigo (BPPV), patient handout, slide set for education purpose, a quick reference pocket guide and mobile apps.

Benign paroxysmal positional vertigo (BPPV) is the commonest cause of vertigo, characterised by repeated episodes of vertigo lasting for less than one minute. BPPV is often triggered by head movements. The duration of symptoms ranges from several days to several months, spontaneous recovery is common, but recurrence also occurs frequently. BPPV is usually diagnosed by a typical history and confirmed by positional testing.

It is believed that most patients with BPPV are suffering from “canalithiasis” where free floating particles called canaliths or otoliths are present in one of the three semicircular canals (SC). 80-90% cases of BPPV are due to posterior SC problems (P-BPPV). More than 90% of BPPV occurs unilaterally. Medications like antihistamine or sedatives are commonly used and evidence suggested the result is not sustainable.

Posterior canal BPPV is treated using canalith repositioning procedures, the most common of which is the Epley manoeuvre (EM). Numerous systematic reviews have shown that this manoeuvre is an effective treatment for posterior canal BPPV and is superior to observation alone.

Effectiveness of the epley manoeuvre in posterior canal benign paroxysmal positional vertigo: a randomised clinical trial in primary care

This paper was published in The British Journal of General Practice in 2019. Researchers performed a multicentre, double-blind randomised controlled trial in two primary care practices in Spain from November 2012 to January 2015. The study evaluates effectiveness at one week, one month, and one year of a single Epley manoeuvre versus a sham maneuver in primary care. The study concluded that a single Epley manoeuvre performed in primary care is an effective treatment for reversing a positive Dix–Hallpike test and reducing vertigo severity in patients with baseline nystagmus in the Dix–Hallpike test.

Clinical practice guideline: meniere's disease

This guideline was published by the American Academy of Otolaryngology- Head and Neck Surgery in the April 2020. Ménière’s disease (MD) is a clinical condition defined by spontaneous vertigo attacks (each lasting 20 minutes to 12 hours) with documented low to mid frequency sensorineural hearing loss in the affected ear before, during, or after one of the episodes of vertigo. It may also present with fluctuating aural symptoms (hearing loss, tinnitus, or ear fullness) in the affected ear.

Intra tympanic gentamicin injection is one of the evidence based treatments for MD patients. With its cochleotoxic and vestibulotoxic effects, gentamicin has a strong predilection toward chemically ablating the vestibular system. Gentamicin has been shown to bring relief to vertigo symptoms in MD patients and is less invasive than surgical ablation.

Patient education and shared decision making regarding gentamicin are important given the possibility of hearing loss from these injections. Although infrequent, hearing may deteriorate in some patients after administration.

Intra tympanic steroid injection is an alternative treatment to gentamicin therapy. While this is less definitive, the favorable risk-benefit profile makes this a good option for some patients.

Efficacy and Safety of a Fixed Combination of Cinnarizine 20 mg and Dimenhydrinate 40 mg vs Betahistine Dihydrochloride 16 mg in Patients with Peripheral Vestibular Vertigo: A Prospective, Multinational, Multicenter, Double-Blind, Randomised, Non-inferiority Clinical Trial

Betahistine has previously been shown to be an effective and safe treatment for peripheral vestibular vertigo. This study was trying to evaluate whether the fixed combination of cinnarizine and dimenhydrinate could be a potentially useful alternative to betahistine dihydrochloride.

This multicenter, double-blind, randomised clinical trial, outpatients from 8 ENT clinics in Austria, Bulgaria, the Czech Republic and Russia were randomly assigned to receive one tablet three times daily of either the fixed combination cinnarizine 20mg/dimenhydrinate 40mg or betahistine dihydrochloride 16 mg for four weeks. Both treatments were found to be well tolerated.

The fixed combination of cinnarizine 20 mg and dimenhydrinate 40 mg was found to be superior to betahistine 16 mg in the improvement of peripheral vestibular vertigo. The present study provided evidence that the fixed - combination preparation being an alternative to betahistine in the treatment of vertigo related to peripheral vestibular disorders.

Internet-based vestibular rehabilitation intervention

Vestibular rehabilitation is an effective intervention for dizziness due to vestibular dysfunction. Balance Retraining is user friendly. This interactive website developed by a group of researchers from The University of Southampton in the United Kingdom was designed to help with dizziness. The website has demonstrations on simple exercises that reduce dizziness, together with suggestions on ways to reduce dizziness related problems, with the intention of promoting the recognition and avoidance of factors that make dizziness worse.

The website requires registration and patients can receive regular email to remind them to perform the exercise on a regular basis.

A single-center, single-blind randomised controlled trial comparing an Internet-based vestibular rehabilitation intervention with regular primary care in treatment from 54 primary care practices in southern England. Patients aged 50 years and older with current dizziness exacerbated by head movements were enrolled. Internet-based vestibular rehabilitation reduces dizziness and dizziness-related disability in older primary care patients without requiring clinical support.¹

The Half Somersault Maneuver

The Half Somersault Maneuver is developed by the researchers in the Department of Otolaryngology at the School of Medicine of University of Colorado. The maneuver can be used as an alternative to the better known Epley maneuver. This video demonstrates in detail how the maneuver can be performed. Studies showed that the half Somersault Maneuver is an effective self treatment of posterior canal benign paroxysmal positional vertigo.²

The Epley maneuver usually requires an assistant as it is difficult to be practised by self. It might precipitate severe vertigo during the exercise and requires a precise sequence of head movements. During these maneuvers, there is also a risk that the particles can be moved into other spinning sensors, resulting in an exacerbation in symptoms rather than improvement.

The Half Somersault can be performed either on the floor or in the centre of a large bed, and therefore does not require that the patient be able to arise from the floor. However, it requires that the patient be able to assume the initial half somersault position, and so it might be difficult for patients of excessive body weight, with knee, neck or back injuries, or with impaired flexibility.