Useful Selected Questions to Ask/Facts to Establish?

Establish whether symptoms are consistent with a vertiginous episode, as above?
Duration of the episode (e.g. vertigo due to benign positional vertigo (BPV) lasts seconds, migraine minutes, Meniere’s disease hours and vestibular neuronitis days).
Any triggering factors? (BPV, for example, is associated with head turning or patient adopting a certain head position).
Any associated symptoms? (Vertigo of peripheral (vestibular) origin is commonly accompanied by nausea, vomiting, hearing disturbances and tinnitus).
Any history or trauma or recent viral illness? (Head injury, for example, is associated with BPV; vestibular neuronitis may follow a recent viral illness).
Past medical history (e.g. association between neurofibromatosis type 2 and acoustic neuroma; multiple sclerosis (MS) with brainstem demyelination causing vertigo of central origin).
Current and past drug history (e.g. aminoglycosides (gentamicin) and streptomycin are vestibulotoxic drugs which may damage vestibular nerves resulting in persistent vertigo).

Differential Diagnoses (Table 8.1)

Basic Investigations

These will be guided by the results of history and detailed neurological examination, including a careful assessment of any nystagmus, cerebellar signs or gait abnormalities.

Bedside hearing tests can be followed up with formal pure tone audiometry if indicated.
Brainstem auditory evoked responses and calorimetry may be helpful.
Investigations directed towards a possible central cause should include imaging (MRI of head—CT is a poor investigation for brainstem/cerebellar pathology) and possibly lumbar puncture (suspected MS).

Basic Management

Refer to Table 8.1 on differential diagnoses.

Table 8.1 Clinical conditions causing vertigo with points to note.

Clinical conditions	Points to note
Benign positional vertigo	Attacks of sudden onset of vertigo lasting seconds (<30 s) and precipitated by head turning. Due to displacement of otoconia in semicircular canal. Can follow head injury. Hallpike manoeuvre^a may help in the diagnosis. Treatment: Self-limiting; physiotherapy (habituation); vestibular sedatives (prochlorperazine or betahistine) may be used acutely but can maintain the problem over the medium/long term
Meniere’s disease	Characterised by vertigo (lasting hours), nausea, vomiting, tinnitus and fluctuating sensorineural hearing loss. Attacks occur in clusters and are due to dilated endolymphatic spaces in membranous labyrinth. Treatment: Symptomatic for acute attacks with cyclizine and betahistine; further treatment may involve operative endolymphatic decompression (hearing conservation) or vestibular neurectomy (ipsilateral deafness)
Vestibular neuronitis	Severe vertigo with an abrupt onset and accompanied by nausea and vomiting. Vertigo lasts for days usually following a probable viral illness. Cyclizine for symptomatic treatment. Full recovery in 3–4 weeks
Central causes (MS, vertebrobasilar TIA, infarction and migraine)	Demyelination or infarction may lead to persistent vertigo compared to a TIA or migraine which produces more transient episodes. Hearing loss and tinnitus are less common in central causes. Nystagmus may be multidirectional, vertical and rotatory in central lesions compared to horizontal nystagmus in peripheral vestibular lesions. Look for associated cranial nerve signs to support a central cause
Acoustic neuroma	Schwannomma arising from superior vestibular division of the eighth nerve. Commonest cerebellopontine angle tumour. Characteristic triad: tinnitus, ipsilateral sensorineural hearing loss and disequilibrium or vertigo. Treatment: Surgical removal or stereotactic radiosurgery
Alcohol and vestibulotoxic drugs (aminoglycosides, for example gentamicin and streptomycin)	See above
a Hallpike manoeuvre involves (in a supine patient; head between examiner’s hands) turning of patient’s head to 30–40 degrees to one side and then rapid lowering of the head to 30 degrees below the level of the couch. In a peripheral cause, for example BPV, vertigo and nystagmus towards undermost ear after a latent period of 5–10 s are induced; this disappears within a minute or so and may reappear on sitting.