Vertigo: Is Your Patient's Head Spinning?

Vestibular disruptions from medications or central nervous system disorders can cause this unsettling sensation.

This Debilitating Condition Responds Well to Treatment, and Pharmacists Can Help

Vertigo’s hallmark symptom—the feeling that the environment is spinning around following quick head movements or sudden changes in body position—typically resolves and then recurs. 1 Symptoms may last from a few seconds to weeks. Onset is unpredictable and episodes range from mild to severe. Nausea and vomiting may occur with moderate to severe episodes, along with nystagmus (involuntary eye movements).

However, vertigo is not a diagnosis, but a symptom of a vestibular or central nervous system disorder. Benign paroxysmal positional vertigo (BPPV) is the most common diagnosis. Symptoms of BPPV result from otoconia, or calcium carbonate crystal buildup (called canalith or ear rocks) that becomes displaced into the semicircular canals of the inner ear’s vestibular labyrinth, stimulating nerve endings and creating movement sensations. ²

BPPV’s lifetime prevalence is 2.4%, with incidence steadily increasing with age. Age- and sex-adjusted incidence is approximately 64 per 100,000 among young adults, increasing up to 8000 per 100,000 for those older than 40 years. ¹ The average age of onset is 51 years. ¹ Recurrence is common, with rates ranging from 26% to 50%. ³ Symptoms generally last from a few seconds to several minutes.

Symptoms lasting hours, days, or weeks suggest disorders other than BPPV. ⁴ Vertigo’s other causes include acute vestibular neuronitis (ear infection, second most common vestibular disorder), Meniere’s disease (an inner ear fluid disorder that causes too much pressure within the inner ear’s endolymphatic system), a perilymph fistula (inner ear fluid leaks into the middle ear), and head trauma. ^5-9

Medication-induced Vertigo

Up to 90% of oral medications list dizziness as a potential side effect. ¹⁰ Additionally, a positive association exists between dizziness and elders using 5 or more medications. ¹¹ Along with dizziness, drug-induced and drug-exacerbated vertigo are linked to several classes of agents. These include aminoglycosides, anticonvulsants (phenytoin), antidepressants (selective serotonin reuptake inhibitors, tricyclics, monoamine oxidase inhibitors), anti-Alzheimer’s agents, antipsychotics, anxiolytics, antihypertensives, mood stabilizers (gabapentin, carbamazepine, oxcarbazepine, lamotrigine), barbiturates, cocaine, diuretics, nitroglycerine, quinine, salicylates, sedatives, and hyponotics. ^5,11,12

Treatment

Treatment options include watchful waiting (for mild forms only), vestibular suppressants, vestibular rehabilitation, and canalith repositioning. Both the American Academy of Otolaryngology-Head and Neck Surgery and the American Academy of Neurology issued treatment guidelines in 2008. Treatment’s initial focus is on acute symptom management. Medications commonly used are antidizziness agents, antiemetics, and antihistaminics or vasodilators. As symptoms subside, agents are discontinued. ¹³

Guidelines recommend against the routine and long-term use of vestibular suppressant medications such as antihistamines or benzodiazepines and strongly recommend particle repositioning as firstline treatment, especially given its high success rate coupled with very low risk. ^13,14 Surgery may be necessary for the 1% of patients who do not respond to repositioning maneuvers. ¹

Particle Repositioning

Two procedures exist for canalith repositioning: the Epley maneuver and the Semont maneuver. The Epley maneuver is the preferred procedure in the United States, partly because it is gentler than the Semont maneuver. The Epley maneuver consists of a series of very brisk movements that result in canaliths moving from the semicircular canals to the utricle. There, crystals may dissolve or adhere to the otolithic membrane. Diazepam or other antinausea agents are prescribed before the procedure because it, too, causes vertigo. Patients who cannot sustain brisk, rapid body movements are poor candidates. ^2,4 In experienced hands, the procedure has a success rate of 95% following one or two sessions. ^1,15

Vestibular rehabilitation is one alternative to particle repositioning. Patients are trained to perform specific exercises that help “retrain” the brain on how it reacts to perceptual cues. Few studies have examined its success rate and those that have done so report lower success rates than those for the Epley maneuver. ¹³

Counseling Guidelines

When patients query you about dizziness, listen carefully to the patient’s description, probing for vertigo’s hallmark symptom of the “room spinning.” Ask if symptoms occur suddenly with certain body movements such as rolling over in bed or looking up. Slow onset suggests infections and/or central nervous system disorders; rapid onset is associated with inner ear disorders. ¹⁶

Vertigo accompanied by hearing loss signals infections, head trauma, or central nervous system disorders. Because approximately 25% of patients with vertigo initially present with migraine, query for vertigo when counseling migraine sufferers. ¹⁷

Review the patient’s medication regimen for agents linked to vertigo, and where an association exists, recommend alternatives to providers. Inform patients that nicotine, alcohol, and caffeine exacerbate vertigo and should be avoided. ^4,5 Acknowledge that episodes can be debilitating, often fueling anxiety and depression, noting that these symptoms may lessen or remit when vertigo is successfully treated. Warn patients not to drive or operate heavy machinery until medical clearance occurs.

The table lists several interventions that may lessen the severity of future episodes for those with mild episodic vertigo.

Final Thought

Vertigo puts patients and others at increased risk for injury. Patient falls, for example, are common. Vertigo accounts for approximately 20% of all falls that require hospitalization. ¹ Fortunately, most forms of vertigo respond well to treatment, and pharmacists are in the unique position of being able to counsel patients during bouts with vertigo. PT

Dr. Zanni is a psychologist and health systems consultant based in Alexandria, Virginia.

References

1. Li J. Neurological manifestations of benign positional vertigo. http://emedicine.medscape.com/article/1158940-overview. Accessed January 9, 2010.

2. Hain T. Benign paroxysmal positional vertigo. www.dizziness-and-balance.com/disorders/bppv/bppv.html. Accessed January 10, 2012.

3. Vestibular Disorders Association. Statistics, how many people have vestibular disorders? www.vestibular.org/vestibular-disorders/statistics.php?searchresult=1&sstring=statistics. Accessed January 10, 2012.

4. Zanni GR, Wick JY. Vertigo: few new spins on a common problem. Consult Pharm. 2006;21:680-696.

5. Chawla N, Olshaker JS. Diagnosis and management of dizziness and vertigo. Med Clin North Am. 2006;90:291-304.

6. Straube A. Nystagmus: an update on treatment in adults. Expert Opin Pharmacother. 2005;6:583-590.

7. Li J. Meniere disease (idiopathic endolymphatic hydrops). http://emedicine.medscape.com/article/1159069-overview. Accessed January 11, 2012.

8. Labuguen RH. Initial evaluation of vertigo. Am Fam Physician. 2006;73:244-251.

9. Vestibular Disorders Association. Perilympt fistuala. www.vestibular.org/vestibular-disorders/specific-disorders/perilymph-fistula.php. Accessed January 12, 2012.

10. Drachman DA. Occam's razor, geriatric syndromes, and the dizzy patient. Ann Intern Med. 2000;132:403-404.

11. Tinetti ME, Williams CS, Gill TM. Dizziness among older adults: a possible geriatric syndrome. Ann Intern Med. 2000;132:337-344.

12. Chang A. Benign positional vertigo in emergency medicine. http://emedicine.medscape.com/article/791414-medication. Accessed January 9, 2012.

13. Silva AL, Marinho MR, Gouveia FM, et al. Benign paroxysmal positional vertigo: comparison of two recent international guidelines. Braz J Otorhinolaryngol. 2011;77:191-200.

14. Bhattacharyya N, Baugh RF, Orvidas L, et al; American Academy of Otolaryngology-Head and Neck Surgery Foundation. Clinical practice guideline: benign paroxysmal positional vertigo. Otolaryngol Head Neck Surg. 2008;139(5)(suppl 4):S47-S81.

15. Helminski JO, Zee DS, Janssen I, Hain TC. Effectiveness of particle repositioning maneuvers in the treatment of benign paroxysmal positional vertigo: a systematic review. Phys Ther. 2010;90:663-678.

16. Samy H. Friedman M, Manolidis S. Dizziness, vertigo, and imbalance. www.emedicine.com/neuro/topic693.htm. Accessed January 11, 2012.

17. Phillips J, Longridge N, Mallinson A, Robinson G. Migraine and vertigo: a marriage of convenience? Headache. 2010;50:1362-1365.