Ep 22 - Diagnosis and management of vertigo in primary care

In this episode, Kevin discusses the case of Lyndsey: a 44-year-old lady who presents to us in primary care with recurrent dizzy episodes over the last month. Lyndsey feels like her head is spinning. She feels nauseated with these episodes, but there is no history of vomiting. Lyndsey can walk unaided but feels very unsteady on her feet during these episodes. The dizziness can last for hours before resolving. There is no clear precipitant to these episodes, and there is no history of headache. Lyndsey denies any hearing loss or tinnitus. What should we do next?

Key references discussed in the episode:

• Welgampola MS et al. Pract Neurol. 2019;19(6):492-501. doi: 10.1136/practneurol-2019-002199.
• Kaski D, Bronstein AM. BMJ. 2012;345:e5809. doi: 10.1136/bmj.e5809.
• Kaski D, Agarwal K, Murdin L. BMJ. 2019;366:l5215. doi: 10.1136/bmj.l5215.
• Turner H, Lavender C, Rea P. Br J Gen Pract. 2020;70(695):310-311. doi: 10.3399/bjgp20X710369.

Useful YouTube links:

• Assessment of nystagmus.
• Hallpike manoeuvre.
• Epley manoeuvre.
• Head impulse, nystagmus, test-of-skew (HINTS) test.

Patient information:

• Ménière’s Society: UK charity for people with vestibular disorders causing dizziness and imbalance.
• Self-treatment of benign paroxysmal positional vertigo (BPPV): home Epley manoeuvre YouTube video.
• NHS information on labyrinthitis and vestibular neuritis (VN).

Key take-home points from the episode:

1. Not all vertigo is labyrinthitis, and we in primary care need to establish a correct underlying diagnosis so as not to miss serious neurological causes but also to ensure that we administer the correct treatment.
2. One of the main sinister diagnoses to exclude is a cerebellar vascular event, and the HINTS clinical examination can reliably distinguish a cerebellar stroke from other causes of vertigo.
3. Diagnosis of VN or labyrinthitis is confirmed by the presence of horizontal unidirectional nystagmus. Treatment is supportive and includes short-term vestibular sedatives such as cyclizine 50 mg three times daily for up to just 3 days; longer-term vestibular sedative therapy can delay the body’s compensatory mechanisms.
4. It is extremely rare for VN or labyrinthitis to recur; if a patient describes recurrent episodes of dizziness, consider a diagnosis of BPPV or vestibular migraine.
5. BPPV is the most common cause of recurrent vertigo in adults we are likely to encounter in primary care, with a lifetime prevalence of around 2.4%.
6. BPPV is positional: vertigo is triggered with head movements. BPPV is diagnosed with the Hallpike manoeuvre, which triggers an attack and nystagmus is observed if positive.
7. Headache may or may not be present in vestibular migraine
8. There is no high-quality evidence to support the use of betahistine for vertigo in Meniere’s disease.
9. Unilateral new-onset and progressive hearing loss or focal neurological signs such as facial weakness, diplopia or limb weakness are red flags in patients presenting with acute vertigo.