Vertigo History

VERTIGO HISTORY (Importance of differentiating PERIPH & CENTRAL VERTIGO)

Dizziness and vertigo, after headache, are the second most common complaint of patients. In a recent survey in more than 30,000 patients, the incidence of dizziness and vertigo was around 20%, rising to 40% in those over 80 years of age.

With a correct diagnosis it is possible to manage almost all the cases very successfully..

History of patient complaints should be on the following four lines:

The the form of vertigo, its duration, possible triggers, and possible accompanying symptoms.

Form of vertigo: rotatory vertigo, i.e. spinning around sensation, versus a postural vertigo or dizziness.

Duration of vertigo: How long the vertigo lasts.- attacks of vertigo which may last only for few seconds and occur up to 30 times a day, as typically found in some forms of vestibular paroxysmia, a disorder analogous to trigeminal neuralgia, or does the patient suffer from a persistent vertigo which may last days, weeks or even years?

Possible triggers bringing on the vertigo: The patient should be asked whether the attacks occur

(1) spontaneously, for example while sitting and having breakfast

(2) only when the patient changes his or her position of the head, sneezes or coughs (typical for perilymph fistula), or

(3) in certain situations such as exposure to malls or department stores (typical for phobic postural vertigo, the second most common cause of vertigo).

Accompanying symptoms: which may indicate whether they originate (from the inner ear (e.g. hypoacusis in one ear or tinnitus) or the brain stem (e. g. double vision, perioral parasthesia, facial palsy, dysarthria, problems with swallowing, or trunk or limb ataxia). If the patient suffers from vertigo plus any of the symptoms arising from the brain stem, the underlying cause may be very serious (e.g. the beginning of basilar thrombosis) and he or she should be instantaneously transferred to a clinic for further investigations.

Differentiate between peripheral and central vertigo

On basis of patient’s history and clinical examination, one can often differentiate between peripheral vertigo versus central vertigo. Peripheral vestibular lesions may arise from the vestibular nerve, the semicircular canal or the otolith organs, namely, the utricle or the sacculus, while the central vestibular forms most often originate from disease conditions of the brain stem, the cerebellum or the connecting pathways between the cerebellum and the brain stem. – the lower part of the brain – Infratentorial. (Supratentorial lesions very rarely cause vertigo.)

Among the non-vestibular disorders the most common form .s psychogenic somatoform vertigo or the so-calted phobic postuural vertigo. It is the most frequent cause of vertigo in patients between 20 and 60 years of age. Visual vertigo is a rare form of non-vestibular vertigo which may occur due to the side effects of certain drugs such as anti-convulsants or drugs to treat Parkinson’s syndrome. Non ¬vestibular causes also include orthostatic problems and cardiac arrhythmias.

Frequency of Vertigo Syndromes

The most common vertigo syndrome seen is benign paroxysmal positioning vertigo, accounting for almost 20% of patients, followed by phobic postural vertigo, the most common form in younger patients.

The central forms of vertigo most often originating from stroke (within the brain stem or cerebellum) and multiple sclerosis and, rarely, from brain stem tumors. Central vestibular vertigo is also seen in patients with neuro-degenerative disorders, especially degenerative disorders of the cerebellum. such as spinal cerebellar ataxia.

Vestibular migraine accounts for more than I 0~6 of the patients. Its diagnosis was often difficult because only two-thirds of the patients with a proven vestibular migraine also have headache during or after the attacks of vertigo. Meniere’s disease was diagnosed in about 7% of the patients. It was. the second most common cause of peripheral vertigo. Vestibular neuritis, which is an inflammation ofthe vestibular nerve, was detected in about 6%, while bilateral vestibulopathy, a failure of both labyrinths, occurred in about 4% of the patients.

Vestibular paroxysmia, which is analogous to trigeminal neuralgia and characterized by recurrent attacks of vertigo, and psychogenic vertigo (other than phobic postural vertigo) were diagnosed in 3-4% each. Perilymph fistula was rarely seen. Only 5% of the patients had no diagnosis.

VERTIGO HISTORY  (Importance of differentiating  PERIPH & CENTRAL VERTIGO)

Dizziness and vertigo, after headache, are the second most common complaint of patients. In a recent survey in more than 30,000 patients, the incidence of dizziness and vertigo was around 20%, rising to 40% in those over 80 years of age.

With a correct diagnosis it is possible to manage almost all the cases very successfully..

History of patient complaints should be on the following four lines:

The the form of vertigo, its duration, possible triggers, and possible accompanying symptoms.

Form of vertigo: rotatory vertigo, i.e. spinning around sensation, versus a postural vertigo or dizziness.

Duration of vertigo: How long the vertigo lasts.- attacks of vertigo which may last only for few seconds and occur up to 30 times a day, as typically found in some forms of vestibular paroxysmia, a disorder analogous to trigeminal neuralgia, or does the patient suffer from a persistent vertigo which may last days, weeks or even years?

Possible triggers bringing on the vertigo: The patient should be asked whether the attacks occur

(1) spontaneously, for example while sitting and having breakfast

(2) only when the patient changes his or her position of the head, sneezes or coughs (typical for perilymph fistula), or

(3) in certain situations such as exposure to malls or department stores (typical for phobic postural vertigo, the second

most common cause of vertigo).

Accompanying symptoms: which may indicate whether they originate (from the inner ear (e.g. hypoacusis in one ear or tinnitus) or the brain stem (e. g. double vision,  perioral parasthesia, facial palsy, dysarthria, problems with swallowing, or trunk or limb ataxia). If the patient suffers from vertigo plus any of the symptoms arising from the brain stem, the underlying cause may be very serious (e.g. the beginning of basilar thrombosis) and he or she should be instantaneously transferred to a clinic for further investigations.

Differentiate between peripheral and central vertigo (See diagram)

On basis of patient’s history and clinical examination, one can often differentiate between peripheral vertigo versus central vertigo. Peripheral vestibular lesions may arise from the vestibular nerve, the semicircular canal or the otolith organs, namely, the utricle or the sacculus, while the central vestibular forms most often originate from disease conditions of the brain stem, the cerebellum or the connecting pathways between the cerebellum and the brain stem. – the lower part of the brain – Infratentorial. (Supratentorial lesions very rarely cause vertigo.)

Among the non-vestibular disorders the most common form .s psychogenic somatoform vertigo or the so-calted phobic postuural vertigo. It is the most frequent cause of vertigo in patients between 20 and 60 years of age. Visual vertigo is a rare form of non-vestibular vertigo which may occur due to the side effects of certain drugs such as anti-convulsants or drugs to treat Parkinson’s syndrome. Non ­vestibular causes also include orthostatic problems and cardiac arrhythmias.

Frequency of Vertigo Syndromes

The most common vertigo syndrome seen is benign paroxysmal positioning vertigo, accounting for almost 20% of patients, followed by phobic postural vertigo, the most common form in younger patients.

The central forms of vertigo most often originating from stroke (within the brain stem or cerebellum) and multiple sclerosis and, rarely, from brain stem tumors. Central vestibular vertigo is also seen in patients with neuro-degenerative disorders, especially degenerative disorders of the cerebellum. such as spinal cerebellar ataxia.

Vestibular migraine accounts for more than I 0~6 of the patients. Its diagnosis was often difficult because only two-thirds of the patients with a proven vestibular migraine also have headache during or after the attacks of vertigo. Meniere’s disease was diagnosed in about 7% of the patients. It was. the second most common cause of peripheral vertigo. Vestibular neuritis, which is an inflammation ofthe vestibular nerve, was detected in about 6%, while bilateral vestibulopathy, a failure of both labyrinths, occurred in about 4% of the patients.

Vestibular paroxysmia, which is analogous to trigeminal neuralgia and characterized by recurrent attacks of vertigo, and psychogenic vertigo (other than phobic postural vertigo) were diagnosed in 3-4% each. Perilymph fistula was rarely seen. Only 5% of the patients had no diagnosis.

Treatment of Vestibular Disorders Basically there are four options on how to treat patients with vestibular disorders:

Physiotherapy is applied as (1) vestibular exercises in patients with unilateral or bilateral vestibular deficit or central vestibular lesions to improve the central compensation or substitution, or (2) liberatory maneuvers to treat benign paroxysmal positioning vertigo.

Medical treatment:

A growing number of agents are available for the medical treatment of vestibular disorders. However, before initiating treatment, it is importal1t to make the diagnosi:; and then to specifically treat the form of vertigo.

Surgery:

The role of surgery has diminished over the past years.

Psychological, psychiatric or behavioral therapy:

This is useful in patients who suffer from phobic postural vertigo.