Referral criteria from primary care - vertigo and recurrent vertigo

For the purpose of referral, vertigo divides conveniently into three categories:

• 1. Spontaneous (no provoking movement: can occur whilst patient is sitting still)
• 2. Movement provoked. (Transient vertigo; imbalance may be more persistent).
• 3. Positional (provoked by movement into or away from certain specific positions, or whilst those positions are maintained)

Spontaneous vertigo:

• Acute Vestibular Failure
  • vestibular neuritis
  • labyrinthitis
  • labyrinthine infarction: Selective occlusion of labyrinthine artery
• Neurological event
  • rare as a cause of acute vertigo. If nystagmus has central features, persists more than 48 hours or if there are other neurological symptoms or signs, consider possibility of posterior circulation CVA, or MS which may present initially with acute vertigo
    
    
• Refer if:
  • associated auditory and/or neurological symptoms and signs
  • nystagmus has central features
  • spontaneous nystagmus persists after 48 hrs
  • symptoms persist after a month

Recurrent episodes of vertigo:

• Migrainous vertigo
  • most common cause of recurrent spontaneous vertigo. Neurological symptoms and signs are absent. Migrainous vertigo is often misdiagnosed as:  
    • Meniere's disease
    • Vestibular neuritis
    • Posterior circulation TIAs
    • Hyperventilation syndrome
    • Other causes (rare) autoimmune inner ear disease; oto-syphilis; vestibular epilepsy
• Refer if:
  • unilateral tinnitus / hearing loss or otorrhoea. (Vestibular Schwannomas rarely present with acute vertigo but audiometry [and possibly MRI] is mandatory)
  • frequent severe attacks not responding to medical management e.g. use of prophylaxis in meniere's disease with betahistine 16mg tds

Positional vertigo:

Benign paroxysmal positional vertigo (BPPV)

• most common cause. Other possible causes include:
  • Central (neurological) positional vertigo
  • Cervicogenic vertigo
  • Migrainous vertigo
    • central positional nystagmus (+/- vertigo) is a common feature. May mimic BPPV.
  • Vertebrobasilar ischaemia
    
    
• Refer if:
  • symptoms persist after 3-4 weeks. (50% resolve spontaneously)
  • treatment not successful.
  • positional vertigo/nystagmus does not have all features of posterior semi circular benign paroxysmal positional vertigo (to exclude central disorder)

Movement induced vertigo:

• Bilateral vestibular hypofunction/failure
  • causes imbalance and oscillopsia (an illusion that the world moves as the patient moves, eg bobs up and down as the patient walks) rather than vertigo. Much worse in the dark
• Reduced dynamic visual acuity (blurred vision on head movement): in severe cases, even reading is difficult. Causes include meningitis, ototoxic drugs, autoimmune disease, head trauma, bilateral 'burnt-out' Meniere's and idiopathic.
• Visual vertigo
  • triggered by movement in the surroundings eg: crowds, traffic, busy supermarket, disco lights etc, or by looking at repetitive patterns eg: striped shirts, patterned floors and fences, supermarket aisle etc, or by flickering light and computer screen. Caused by 'visuo-vestibular conflict', visual dependence or visual substitution often following an acute vestibular event.
• Central (brainstem / cerebellar) disorder
• Refer if:
  • any suspicion of central disorder
  • still significantly symptomatic after a month, for confirmation of the diagnosis. More specific or 'customized' exercises may be needed, preferably supervised by a specialist physiotherapist

Red flag symptoms associated with vertigo that require 'prompt' referral

• Unilateral tinnitus and/or hearing loss/dysacusis
• Unilateral otorrhoea
• neurological symptoms or signs
• nystagmus has central features
• spontaneous nystagmus persists after 48 hrs
• positional vertigo/nystagmus which does not have all the features of posterior semi circular BPPV
• significant vertigo/ imbalance persist after a month
• positive fistula sign: pressure on the tragus reproduces symptoms (suggests endolymphatic fistula)

Notes:

• BPPV
  • brief attacks (< 1 min) precipitated by looking up, bending, turning over in bed, sitting up from lying and neck extension. General sense of imbalance affects 50% and may be main complaint
    • note that patients with BPPV may deny positional symptoms as they become adept at avoidance. Diagnostic findings on Hallpike test (refer to Epley attachment)
    • for posterior semicircular canal BPPV (more than 90% of BPPV):
      • upbeat and torsional nystagmus beating to undermost ear, latent period of 2 - 40 sec, fatigues in <30 sec, reduced or absent on repeating test.
      • the horizontal and anterior semicircular canals can be affected but the diagnostic test and the nystagmus are different

Reference:

• Western Sussex Hospitals NHS Trust (2010). Speciality: audiovestibular medicine clinical problems: dizziness, vertigo and imbalance