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The
most frequent causes of vertigo
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| The
following are the most frequent diagnoses established in 7205 patients
(in decreasing order of importance) at our supraregional special outpatient
clinic for vertigo: Benign peripheral paroxysmal positioning vertigo (BPPV) - 18.6% Phobic postural vertigo - 15.6% Central vestibular forms of vertigo - 12.4% Basilar migraine - 10.2% Menière's disease - 9.4% Vestibular neuritis 7.4% The different syndromes of vertigo can be divided into peripheral vestibular (involving the labyrinth or the vestibular nerve), central vestibular (generally of the brainstem or developing from the cerebellum), and psychogenic forms. |
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Attacks
of peripheral vestibular vertigo
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BENIGN
PERIPHERAL PAROXYSMAL POSITIONING VERTIGO
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| SYMPTOMS:
attacks of rotatory vertigo,
induced by changes in the position of the head or bodylasting < 1
minute, accompanied by oscillopsia, nausea, and vomiting. CLINICAL FINDINGS: when positioned on the side of the affected ear, a positioning nystagmus is elicited which beats with a crescendo-decrescendo course with a rotatory component towards the affected ear and a vertical upward component and becomes less intense after several positioning maneuvers. MECHANISM: canalolithiasis ("'stone in the ear") of the (generally) posterior semicircular canal THERAPY: liberatory maneuvers |
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VESTIBULAR
NEURITIS
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| SYMPTOMS:
acute onset of rotatory vertigo for days with oscillopsia, tendency
to fall toward the affected side, nausea, and vomiting CLINICAL FINDINGS: rotating spontaneous nystagmus to the non-affected side, pathological head-impulse test ADDITIONAL EXAMINATIONS: electronystagmography with caloric irrigation: unilateral caloric hypoexcitability or non-excitability MECHANISM: Most likely: reactivation of a latent HSV 1 inflammation THERAPY: antivertiginous drugs given for the symptoms (for example, Vomex A) for maximally 3 days, glucocorticoids for a causative treatment, balance exercises to improve central compensation |
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MENIÈRE'S
DISEASE
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SYMPTOMS:
classic triad of 1. rotatory vertigo lasting for hours and up to one day 2. unilateral, generally low-frequency ringing of the ears ("buzzing") 3. unilaterally reduced hearing (frequently an additional "pressure" in the affected ear) CLINICAL FINDINGS: during the attack spontaneous nystagmus often hypacusis, fullness in one ear and tinnitus ADDITIONAL EXAMINATIONS: during a longer course of illness there are frequently between attacks of unilateral hypacusis and caloric hypo-excitability MECHANISM: Increased pressure in the endolymphatic space and intermittent ruptures of the endolymphatic membranes THERAPY: long-term drug treatment with betahistine (e.g., Betahistine-dihydrochloride 48 mg/tid > 6-12 months) |
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BILATERAL
VESTIBULOPATHY
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| SYMPTOMS:
postural vertigo with oscillopsia while walking, increases in the
dark and on unlevel ground, in part with disturbances of memory,
no symptoms under static conditions CLINICAL FINDINGS: bilateral pathological head-impulse test; broad-based gait MECHANISM: bilateral loss of the vestibular organs with disturbance of the vestibulo-ocular and vestibulo-spinal reflexes THERAPY: balance training, prophylaxis, causative treatment |
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VESTIBULAR
PAROXYSMIA
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SYMPTOMS:
spontaneous recurrent attacks of vertigo lasting seconds to minutes
(generally rotatory) CLINICAL FINDINGS: during the attack spontaneous nystagmus, tendency to fall ADDITIONAL EXAMINATIONS: most often normal, MRI shows neurovascular cross-compression in 95% of the patients (also occurs in 30% of healthy persons), exclusion of central causes by means of MRI, spinal tap, and evoked potentials MECHANISM: neurovasular compression of the VIIIth nerve with ephaptic transfer of excitation THERAPY: carbamazepine (100 to 300 mg/day, or oxacarbamazepin), in case of allergy or no efficacy try phenytoin or gabapentin |
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CENTRAL VESTIBULAR VERTIGO
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SYMPTOMS: rotatory or postural vertigo
with or without nausea of various duration, generally accompanying
symptoms such as double vision, perioral paresthesias, facial paralysis,
swallowing problems, dysarthria, disorders of sensations in the arms/legs,
paresia, ataxia CLINICAL FINDINGS : generally central ocular motor disorders, central vestibular syndrome, nystagmus such as downbeat or upbeat nystagmus and disorders of the brainstem/cerebellum (see above). |
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VESTIBULAR
MIGRAINE
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SYMPTOMS: attacks of rotatory
or postural vertigo lasting minutes to hours, headache only in two-thirds
of the patients CLINICAL FINDINGS : generally slight central ocular motor disorders in attack-free interval THERAPY: treatment of symptoms: antiemetics (metoclopramide, domperidone), analgesics (acetylsalicylic acid, paracetamol) Prophylactic treatment: beta-receptor blockers (metoprolol succinate, propranolol), valproic acid or topiramate. |
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PSYCHOGENIC
FORMS OF VERTIGO
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PHOBIC
POSTURAL VERTIGO
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SYMPTOMS: psychogenic disorders
and subjective fluctuations of stance/gait, attack-like fears of falling
but without falls, often elicited by typical situations accompanied
by fear or vegetative disturbances; improvement during sport and after
light alcohol consumption. CLINICAL FINDINGS : normal neurological results and tests MECHANISM: disturbance of the mechanism controlling spatial constants; increased self-observation of balance THERAPY: explanation of the psychogenic mechanism, self-monitored desensitization with behavioral therapy. Selective serotonin-reuptake inhibitors. |
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