Diagnosis and treatment of vertigo and dizziness

Abstract

Introduction: Vertigo is not a separate disease process, but a multisensory and sensorimotor syndrome with various etiologies and pathogeneses. It is among the commonest symptoms presented to doctors, with a lifetime prevalence of around 20% to 30%. Patients have often consulted multiple physicians before a diagnosis is made and therapy initiated.

Methods: Selective literature research and review of the guidelines of the German Neurological Society.

Results: A careful history remains the cornerstone of diagnosis. Once the correct diagnosis is made, specific and effective treatments are available for most peripheral, central, and psychogenic forms of dizziness. Treatment may include medication, physiotherapy, and psychotherapy; a few limited cases may require surgical treatment. The treatment of choice for acute vestibular neuritis is the administration of corticosteroids. Menière's disease is treated with high-dose, long-term betahistine. A new approach to the management of downbeat and upbeat nystagmus, and of episodic ataxia type 2, involves the use of aminopyridines as potassium-channel blockers. Close multidisciplinary cooperation is essential in dizziness, and further multicenter studies are needed.

Keywords: Menière’s disease; dizziness; migraine; presenting complaint; vertigo; vestibular disorder.

Figure 1

Figure 1: The treatment of benign paroxysmal positioning vertigo (BPPV) with the Semont maneuver. The illustration shows the treatment of BPPV due to canalolithiasis of the right posterior semicircular canal. a) In the initial, sitting position, the head is turned 45° to the side of the unaffected ("healthy") ear. b) The patient is laid on the right side, i.e., on the side of the affected ear, while the head is kept in 45° of rotation to the other side. This induces movement of the particulate matter in the posterior semicircular canal by gravity, leading to rotatory nystagmus toward the lower ear that extinguishes after a brief interval. The patient should maintain this position for about one minute. c) While the head is still kept in 45° of rotation toward the side of the healthy ear, the patient is rapidly swung over to the side of the unaffected ear, so that the nose now points downward. The particulate matter in the semicircular canal now moves toward the exit from the canal. This position, too, should be maintained for at least one minute. d) The patient returns slowly to the initial, sitting position. The particulate matter settles in the utricular space, where it can no longer induce rotatory vertigo. This sequence (a-d) should be performed three times in a row three times per day, in the morning, at noon, and at night. Most patients are free of symptoms after doing this for three days.

Figure 2

The symptoms and clinical findings in right vestibular neuritis. The rotatory vertigo often arises acutely and lasts from several days to a few weeks. Clinical examination is performed with Frenzel’s goggles that are lit from within and contain magnifying lenses (+16 diopters). These goggles prevent the suppression of spontaneous nystagmus by visual fixation and make the patient’s eye movements easier to observe. Spontaneous nystagmus away from the affected side is seen, along with a falling tendency, ocular tilt, and deviation of the subjective visual vertical axis toward the affected side.

Figure 3

Mean peak slow phase velocities (PSPV) of DBN measured by 2-D recordings of eye movements. The two graphs on the left show the original data of mean PSVP of each subject: (a) Control versus 3,4-DAP, (c) control versus placebo. The two graphs in the middle give the box plot charts with the mean, median, and the 50% percentile as well as the range for control versus 3,4-DAP (b) and control versus placebo (d). 3,4-DAP reduced mean PSPV of DBN from 7.2 ± 4.2 deg/s (mean ± SD) before treatment to 3.1 ± 2.5 deg/s 30 min after ingestion of the 3,4-DAP (n = 17, p < 0.001, two-way ANOVA). The inset (e) shows an original recording of the vertical eye position before (upper trace) and 30 min after ingestion of the drug (lower trace). From: Strupp M, Schuler O, Krafczyk A, Jahn K, Schautzer F, Buttner U, Brandt T: Treatment of downbeat nystagmus with 3,4-diaminopyridine: a placebo-controlled study. Neurology 2003; 61: 165-70, with the kind permission of Lippincott Williams and Wilkins.