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Vertigo and dizziness– advice for initial management in primary care
Dept Clinical Neurosciences, NHS Lothian. 2022
Please note this is only designed as a summary of management
Please consult BNF for contraindications, cautions, side effects, pregnancy etc. www.refhelp.scot.nhs.uk/
Dizziness – vertigo, light-headedness, presyncope, dissociation or disequilibrium?
Dizziness is a very common symptom and has a wide differential, mostly benign. The history will help distinguish what the patient means, although patience is often required. Light-headedness/presyncope = a feeling you might pass out. Dissociation = a spaced out feeling as if disconnected from your body or the world around you. Here we focus on vertigo, which is the illusion of movement and familiar to many people after drinking too much alcohol. Vertigo arises from lesions of either the inner ear (vestibular apparatus) or the brain, although the former is far more common.
Common causes of vertigo (in order of frequency)
- Benign paroxysmal positional vertigo (BPPV); short lasting (seconds) bursts of vertigo with movement, typically rolling over in bed, getting in/out bed/chairs/car, looking up at cupboards, hanging up washing. Common after head injury, under-recognised, but eminently treatable (not with drugs). Once you cure your first BPPV patient you will wish you learnt how to do an Epley sooner!
- Vestibular migraine: the only common brain cause of vertigo, attacks last hours to days, usually associated with other migrainous features but not always headache.
- Acute vestibular syndrome (aka labyrinthitis, vestibulo-neuronitis); better known to GPs than hospital doctors, typically disabling vertigo lasting days, most recover fully, can occasionally recur and/or leads to PPPD (see below).
- Persistent perceptual postural dizziness (PPPD): not vertigo, but may evolve after vertigo, persistent disequilibrium, the “chronic fatigue syndrome” of the brain/inner ear axis (https://www.neurosymptoms.org/en_GB/symptoms/fnd-symptoms/dizziness-including-pppd-persistent-postural-perceptual-dizziness/ opens a new window)
- Meniere’s disease/syndrome: ENT classic, vertiginous episodes last hours usually with associated unilateral aural fullness/tinnitus/fluctuating hearing loss.
All other causes of isolated vertigo including central causes such as TIA, acoustic neuroma, MS are rare or very rare. Brainstem TIA and MS nearly always presents with vertigo + other brainstem/ focal symptoms.
M.A & J.S. 20-12-22
