Vertigo
Vertigo - Summary
Vertigo is a symptom, not a diagnosis. It refers to a perception of spinning or rotation of the person or their surroundings in the absence of any actual physical movement.
Vertigo can adversely affect quality of life and affect activities such as driving and employment. Vertigo also increases the likelihood of falls, anxiety, and depression.
Most balance problems that present in primary care are not true rotatory vertigo, but generalized unsteadiness.
It is important to differentiate peripheral from central vertigo.
Peripheral vertigo is caused by altered activity in the balance organs of the inner ears, from which the brain detects a sensation of movement (e.g. benign paroxysmal positional vertigo, vestibular neuronitis, labyrinthitis, and Meniere’s disease).
Central vertigo is caused by disturbance to the visual-vestibular interaction centres in the brainstem and cerebellum, or to sensory pathways to and from the thalamus (e.g. migraine, stroke, transient ischaemic attack, cerebellar tumour, acoustic neuroma, and multiple sclerosis).
Examination should include looking for facial asymmetry, examination of the ear, testing of cranial nerves and cerebellar function, examination of the eyes, and checking for signs of peripheral neuropathy and abnormal gait.
Specific tests such as Romberg’s test, the Hallpike manoeuvre, the head impulse test, and Unterberger’s test can give useful information on the origin of vertigo.
If peripheral vertigo is suspected, the history and examination findings can be used to differentiate between conditions:
In benign paroxysmal positional vertigo (BPPV), episodes of vertigo are induced by moving the head and episodes last for seconds (but may be described as minutes).
In vestibular neuronitis and labyrinthitis, vertigo usually persists for several days and gradually improves with time. In vestibular neuronitis there is no hearing loss or tinnitus. People with labyrinthitis report sudden hearing loss associated with vertigo, and tinnitus may be present, but they do not usually have the feeling of fullness in the ear that is described by people with Meniere's disease.
In Meniere's disease, episodes of vertigo occur spontaneously, are not provoked by position change, and last much longer (30 minutes to several hours) than in BPPV. Tinnitus, hearing loss, and fullness in the ear are present in Meniere's disease, but not usually in BPPV or vestibular neuronitis.
A central cause of vertigo should be suspected when the signs and symptoms do not match the features of any of the peripheral causes with reasonable accuracy.
Features increasing suspicion of a central cause of vertigo include persistent, severe, or prolonged vertigo; new-onset headache; focal neurological signs and symptoms; central-type nystagmus; an abnormal response to the Hallpike manoeuvre; and prolonged, severe imbalance.
Management of vertigo will depend on the suspected underlying cause and may include:
Admission to hospital, if there are worrying features.
Referral to a specialist for confirmation of the diagnosis.
Use of repositioning manoeuvres to relieve symptoms.
Advice on driving, work, and prevention of falls.
Use of short-term symptomatic drug treatment.
Have I got the right topic?
This CKS topic covers the diagnosis of vertigo, how to determine the underlying cause of vertigo, and the management and referral in primary care of vertigo of unknown cause, labyrinthitis, and central causes of vertigo.
This CKS topic does not cover the diagnosis, management, and referral of people with other forms of dizziness (for example light-headedness). The management of migrainous vertigo and less common causes of vertigo (for example acoustic neuroma, perilymph fistula) is also not covered.
There are separate CKS topics on Benign paroxysmal positional vertigo, Brain tumour - suspected, Falls - risk assessment, Head injury, Meniere's disease, Migraine, Stroke and TIA, Tinnitus, and Vestibular neuronitis.
The target audience for this CKS topic is healthcare professionals working within the NHS in the UK, and providing first contact or primary health care.
How up-to-date is this topic?
How up-to-date is this topic?
Changes
January 2011 — minor update. Text amended. The management of benign paroxysmal positional vertigo is now covered in the CKS topic on Benign paroxysmal positional vertigo and the management of vestibular neuronitis is now covered in the CKS topic on Vestibular neuronitis.
January to April 2010 — this is a new CKS topic. The evidence-base has been reviewed in detail, and recommendations are clearly justified and transparently linked to the supporting evidence.
Update
New evidence
Evidence-based guidelines
No new evidence-based guidelines since 1 December 2009.
HTAs (Health Technology Assessments)
No new HTAs since 1 December 2009.
Economic appraisals
No new economic appraisals relevant to England since 1 December 2009.
Systematic reviews and meta-analyses
Systematic reviews published since the last revision of this topic:
Helminski, J.O., Zee, D.S., Janssen, I., and Hain, T.C. (2010) Effectiveness of particles repositioning maneuvers in the treatment of benign paroxysmal positional vertigo: a systematic review. Physical Therapy. 90(5), 663-678. [Abstract] [Free Full-text]
Primary evidence
Observational studies published since the last revision of this topic:
Maarsingh, O.R., Dros, J., Schellevis, F.G., et al. (2010) Causes of persistent dizziness in elderly patients in primary care. Annals of Family Medicine 8(3), 196-205. [Abstract] [Free Full-text]
New policies
No new national policies or guidelines since 1 December 2009.
New safety alerts
No new safety alerts since 1 December 2009.
Changes in product availability
No changes in product availability since 1 December 2009.
Goals and outcome measures
Goals
To support primary healthcare professionals to:
Determine the underlying cause of vertigo, where possible
Identify people with vertigo who require urgent referral or admission to hospital
Manage, in primary care, benign paroxysmal positional vertigo and vestibular neuronitis
Appropriately refer people with vertigo to a specialist
Background information
Definition
What is it?
Vertigo is a symptom, not a diagnosis. It refers to a perception of spinning or rotation of the person or their surroundings in the absence of any actual physical movement.
In contrast, dizziness is a non-specific term that people commonly use to describe a number of symptoms, including:
Vertigo.
Presyncope — a sensation of being about to lose consciousness, usually caused by a decrease in global cerebral blood flow.
Disequilibrium — a feeling of unsteadiness or of being 'off balance'. Usually, it occurs when standing.
Light-headedness — not clearly defined.
Causes
What causes it?
Peripheral vertigo — is caused by altered activity in the balance organs of the inner ears. The difference in activity between the two ears leads to a difference in sensory inputs to the vestibular nuclei, from which the brain detects a sensation of movement. Causes of peripheral vertigo include:
Benign paroxysmal positional vertigo. This is thought to be caused by otolith particles becoming dislodged into the semi-circular canals and causing movement of the fluid of the inner ear after certain head movements. It commonly occurs spontaneously, particularly in older people, but can be precipitated by a head injury, ear surgery, or following an episode of labyrinthitis [Baloh et al, 1987; Lempert et al, 1995; Hanley et al, 2001].
Vestibular neuronitis and labyrinthitis. These terms have been used interchangeably in the past but specific terminology is now recommended by experts.
Vestibular neuronitis is thought to be due to inflammation of the vestibular nerve and often occurs after a viral infection [Hanley et al, 2001; Kuo et al, 2008a; Macleod and McAuley, 2008].
Labyrinthitis involves inflammation of the labyrinth and the vestibular nerve and is often attributed to a viral infection [Swartz and Longwell, 2005; Kuo et al, 2008a].
Meniere's disease is thought to be caused by endolymphatic hypertension (hydrops) in the inner ear. It may occur as a result of viral or bacterial ear infections, or metabolic or immune disorders [Hanley et al, 2001; Minor et al, 2004; Sajjadi and Paparella, 2008].
Uncommon causes of peripheral vertigo include perilymphatic fistula, labyrinthine concussion, vestibular ototoxicity (for example drug-related damage), vestibular paroxysmia, and syphilis.
Central vertigo — is caused by disturbance to the visual-vestibular interaction centres in the brainstem and cerebellum, or to sensory pathways to and from the thalamus.
Migraine is the most common cause of central vertigo (and is possibly one of the most common causes of vertigo). It may present with peripheral features and can be difficult to distinguish from early Meniere's disease.
Uncommon causes of central vertigo are stroke and transient ischaemic attack, cerebellar tumour, acoustic neuroma, and multiple sclerosis.
[Swartz and Longwell, 2005; Kuo et al, 2008b; Barraclough and Bronstein, 2009]
Prevalence
How common is it?
Most balance problems that present in primary care are not true rotatory vertigo, but generalized unsteadiness.
A review of five studies showed that, of people presenting with symptoms of dizziness in the community, around a third were found to have vertigo, this proportion increasing with age [Hanley et al, 2001].
In a community study of more than 2000 adults, 7% had experienced true vertigo in the previous year [Barraclough and Bronstein, 2009].
A full-time general practitioner is likely to see 10–20 people with vertigo in 1 year [Barraclough and Bronstein, 2009].
It is uncertain whether peripheral vertigo is more common than central vertigo.
In a prospective study in primary care of 70 people with vertigo [Hanley and O'Dowd, 2002]: 43% had benign paroxysmal positional vertigo; 40% had vestibular neuronitis; 10% had Meniere's disease; and the remainder had stroke, transient ischaemic attack, multiple sclerosis, or psychogenic vertigo. However, these findings may be misleading as:
The study did not report people for whom the cause of vertigo remained undiagnosed. No diagnosis is made in a substantial proportion of people.
It is unclear whether they were working diagnoses prior to further investigation or confirmed diagnoses.
CKS expert reviewers highlighted the study overestimated the incidence of Meniere's disease (which is rare), and omits migrainous vertigo (which may be one of the most common causes of vertigo).
Complications
What are the complications?
Vertigo:
Can adversely affect quality of life. The symptoms can be disabling, affecting activities such as driving and employment.
Increases the risk of falls.
Increases the likelihood of anxiety or depression.
Determining the cause of vertigo
Determining the cause of vertigo
Confirming vertigo
How do I know my patient has vertigo?
People with vertigo usually describe rotatory or spinning symptoms. To determine that the person has vertigo rather than non-rotatory dizziness (for example presyncope, disequilibrium, or light-headedness) ask in detail about their symptoms; consider asking:
'When you have dizzy spells, do you feel light-headed or do you see the world spin around you as if you had just got off a playground roundabout?'
Basis for recommendation
Basis for recommendation
This question was originally used in a study to identify transient neurological dysfunction in people 65 years of age or older [Evans, 1990]. Its use in primary care for determining whether the person is describing true vertigo has been suggested by experts [Hanley and O'Dowd, 2002; Barraclough and Bronstein, 2009].
Questions to identify the cause
What questions should I ask to help identify a cause of vertigo?
Ask about:
The vertigo.
Timing of symptoms — duration, onset, frequency, severity.
Aggravating factors (such as movement of the head).
Effect on daily activities (such as walking).
Associated symptoms.
Otological — such as hearing loss, ear discharge, a feeling of fullness in the ear, or tinnitus (unilateral or bilateral).
Neurological — such as headache, diplopia, visual disturbance, dysarthria or dysphagia, paraesthesia, muscle weakness, or ataxia.
General autonomic symptoms — nausea and vomiting, sweating, or palpitations.
Migraine aura — visual or olfactory symptoms.
Relevant medical history.
Recent upper respiratory tract infection or ear infection — suggestive of vestibular neuronitis or labyrinthitis.
Migraine — increases the likelihood of the vertigo being migrainous.
Head trauma or recent labyrinthitis — suggests benign paroxysmal positional vertigo.
Direct trauma to the ear — consider perilymph fistula.
Anxiety or depression — can exacerbate dizziness or vertigo. Rarely, anxiety or depression may manifest as dizziness or vertigo, especially if the person hyperventilates.
Cardiovascular risk factors (such as previous angina or myocardial infarction, diabetes, hypertension, smoking, atrial fibrillation) — increase the likelihood of stroke as the cause of vertigo.
Drugs (such as aminoglycosides, furosemide, antidepressants, antipsychotics, anticonvulsants [carbamazepine and phenytoin]) — may cause vertigo.
Acute intoxication with alcohol — may cause vertigo.
Family history of migraine or Meniere's disease — may increase the likelihood of these conditions.
Basis for recommendation
Basis for recommendation
This recommendation is based on expert opinion in narrative reviews [Kuo et al, 2008b; Macleod and McAuley, 2008] and the opinion of CKS expert reviewers.
Clinical signs to identify the cause
What clinical signs should I look for to identify the cause of vertigo?
Look at the person's face for signs of asymmetry suggestive of peripheral facial nerve involvement or a cerebrovascular event.
Examine the ear — look for infection, discharge, vesicular eruptions, and signs of cholesteatoma.
Perform a neurological examination:
Test cranial nerves and cerebellar function.
Examine the eyes for nystagmus:
May be more obvious if the sclera are exposed and the movement of local blood vessels observed.
Note its direction and whether it is affected by changing the direction of gaze, or fixing the eyes on an object.
Perform fundoscopy.
Check for signs of peripheral neuropathy.
Examine the person's gait and their ability to stand unaided.
Use specific clinical tests:
Romberg's test — to identify instability of either peripheral or central cause (although it is not a sensitive test for differentiating between them).
Hallpike manoeuvre — to help make a diagnosis of benign paroxysmal positional vertigo.
Head impulse test — to help determine whether the cause of vertigo is peripheral or central (although it is not a sensitive test for this purpose).
Unterberger's test — to identify damage to one of the labyrinths.
Romberg's test
Romberg's test
To carry out the test:
Ask the person to stand up straight with their feet together (or at a distance at which they are steady) with their arms outstretched, and then shut their eyes.
Stay close by, to prevent the person falling if they become unsteady.
If the person cannot maintain their balance when their eyes are closed, the test is positive (the person will usually fall to the side of the lesion).
Interpreting test results
A positive test suggests a problem with proprioception or vestibular function. It is therefore useful in identifying instability associated with vertigo, but not in distinguishing between peripheral and central causes of vertigo.
Romberg's test can also be positive in neuromuscular disorders and may not be reliable in very elderly people.
Hallpike manoeuvre
Hallpike manoeuvre
Be cautious if considering the Hallpike manoeuvre if the person has a neck or back problem, or carotid stenosis, as it involves turning the head and extending the neck. If in doubt about the safety of the manoeuvre, seek specialist advice or refer the person to a medically qualified balance specialist (such as an ear, nose, and throat specialist or an audiovestibular physician).
Advise the person to report symptoms of vertigo during the procedure.
To carry out the manoeuvre [Lempert et al, 1995]:
Advise the person that they may experience transient vertigo during the procedure.
Ask the person to keep their eyes open throughout the manoeuvre and to stare at the examiner's nose.
Ask the person to sit upright on the couch with their head turned 45 degrees to one side. If the person has neck problems, ask them to turn their head laterally if this is possible.
From this position, lie them down rapidly until their head is extended 30 degrees over the end of the bed with one ear downwards. If the person has neck problems, this movement can be done without neck extension over the side of the couch — this should be sufficient to provoke nystagmus if the person has active BPPV.
Observe their eyes closely for up to 30 seconds for the development of nystagmus, and note its type and direction.
Support the head in position and sit the person up.
Repeat with the head rotated 45 degrees to the other side.
The test is positive for benign paroxysmal positional vertigo if vertigo and nystagmus (torsional and beating towards the ground) are present and nystagmus shows latency, fatigue, and adaptation.
Video illustrations of performing the Hallpike manoeuvre and of types of nystagmus are available at the Imperial College London Faculty of Medicine website.
Head impulse test
Head impulse test
Use caution if the person has neck pathology as it involves rapid repositioning of the head [Kuo et al, 2008b]. Always start by asking the person to rotate their neck themselves to assess for any limitation of neck movement. If in doubt about the safety of the manoeuvre, seek specialist advice or refer the person to a balance specialist.
To carry out the test [Macleod and McAuley, 2008]:
Advise the person to sit upright and to fix their gaze on the examiner.
Then rapidly turn the head 20 degrees to one side and watch the eyes for corrective abnormal movements (saccades).
Repeat several times to the same or opposite side, randomly and unpredictably, until satisfied as to the consistent presence or absence of the corrective saccade.
A corrective saccade represents a positive test and implies moderate to severe loss of function of the horizontal semi-circular canal on the side to which the test is positive.
Video illustrations of performing the head impulse test and demonstrating corrective saccades are available at the Imperial College London Faculty of Medicine website.
Unterberger's test
Ask the person to march on the spot for 30 seconds with their eyes closed and observe them for lateral rotation.
If there is no rotation, there is symmetrical labyrinthine function. If there is labyrinthine damage, the person will rotate to the side of the affected labyrinth.
Basis for recommendation
Basis for recommendation
Examination
The recommendation on what examination to perform is based on expert opinion in narrative reviews [Kuo et al, 2008b; Macleod and McAuley, 2008; Seemungal and Bronstein, 2008] and the opinion of CKS expert reviewers.
Diagnostic manoeuvres
The Hallpike manoeuvre and the head impulse test are recommended based on expert opinion from CKS reviewers and expert opinion in a narrative review that these tests help to make the diagnosis of vestibular (peripheral vertigo) rather than brainstem (central vertigo) disease in primary care [Barraclough and Bronstein, 2009].
A prospective study of vertigo in primary care showed that the Hallpike manoeuvre is easy to introduce into daily practice. General practitioners (GPs) involved in the study used it on 61% of people presenting with vertigo. The positive predictive value of a positive Hallpike test for a diagnosis of benign paroxysmal positional vertigo was 83.3%, with a negative predictive value of 52% [Hanley and O'Dowd, 2002].
Romberg's and Unterberger's tests are recommended on the basis of expert opinion in a text book of clinical examination [Munro, 1995; Douglas et al, 2009] and the opinion of CKS expert reviewers.
Determining the cause
How should I determine the cause of vertigo?
Determine whether vertigo is central or peripheral.
Suspect a central cause of vertigo when the signs and symptoms do not match the features of any of the peripheral causes with reasonable accuracy.
Features increasing suspicion of a central cause of vertigo include:
Persistent, severe, or prolonged vertigo (although this may also indicate severe Meniere's disease, or severe vestibular neuronitis).
New-onset headache.
Focal neurological symptoms and signs (for example visual disturbance, visual field defects, dysarthria, weakness, numbness, and gait ataxia).
Central-type nystagmus (for example vertical nystagmus). Video illustrations of central nystagmus are available at the Imperial College London Faculty of Medicine website.
Abnormal response to the Hallpike manoeuvre (for example vertical nystagmus without latency, adaptation, or fatiguability; excessive nausea and vomiting).
Prolonged, severe imbalance (an inability to stand up even with the eyes open).
In central vertigo:
Nausea and vomiting are usually less severe than with peripheral causes.
Hearing is usually normal, except in acute brainstem stroke, when a unilateral hearing loss can occur. Hearing may be symmetrically reduced if a coincidental hearing loss is present.
There is no sensation of pressure in the ear as may be present in Meniere's disease.
The head impulse test is negative.
If peripheral vertigo is suspected, use the history and examination findings to differentiate between conditions:
In benign paroxysmal positional vertigo (BPPV), episodes of vertigo are induced by moving the position of the head and episodes last for seconds (but may be described as minutes).
In vestibular neuronitis and labyrinthitis, vertigo usually persists for several days and gradually improves with time.
In vestibular neuronitis there is no hearing loss or tinnitus.
People with labyrinthitis report sudden hearing loss associated with vertigo, and tinnitus may be present, but they do not usually have the feeling of fullness in the ear that is described by people with Meniere's disease.
In Meniere's disease, episodes of vertigo occur spontaneously, are not provoked by position change, and last much longer (30 minutes to several hours) than in BPPV. Tinnitus, hearing loss, and fullness in the ear are present in Meniere's disease, but not usually in BPPV or vestibular neuronitis.
For more information on examination findings, see Table 1.
Table 1. Features that differentiate peripheral from central vertigo.| Test | Clinical features | Peripheral | Central |
|---|---|---|---|
| Hallpike manoeuvre (specific test for BPPV) | Latency of symptoms and nystagmus | Usually less than 30 seconds | None |
| Duration of nystagmus | Typically < 1 minute | Typically > 1 minute | |
| Fatiguability of symptoms* | Yes (in classic BPPV) | No | |
| Head impulse test | — | May be positive with acute unilateral vestibular loss (negative in BPPV) | Negative |
| — | Postural instability | Able to walk, may be mild instability in one direction | Falls on walking |
| Hearing loss or tinnitus | Possible | Uncommon, but may occur | |
| Central neurological symptoms | No | Usually | |
Basis for recommendation
Basis for recommendation
Approach to determining the cause of the vertigo
The approach to determining the cause of the vertigo is based on that suggested by experts in a narrative review of the diagnosis of vertigo in general practice [Barraclough and Bronstein, 2009] and the opinion of CKS expert reviewers.
Clinical features of central vertigo
The features of conditions causing central vertigo are based on expert opinion in narrative reviews [Hanley et al, 2001; Hain and Uddin, 2003; Lempert and von Brevern, 2005; Macleod and McAuley, 2008; Sajjadi and Paparella, 2008; Seemungal and Bronstein, 2008] and the opinion of CKS expert reviewers.
Clinical features of peripheral vertigo
The differentiating features of conditions causing peripheral vertigo are based on expert opinion in narrative reviews [Kuo et al, 2008b; Macleod and McAuley, 2008; Seemungal and Bronstein, 2008] and the opinion of CKS expert reviewers.
Features of benign paroxysmal positional vertigo
How do I know my patient has benign paroxysmal positional vertigo?
Benign paroxysmal positional vertigo (BPPV) can affect people of any age, but commonly presents at around 50 years of age. Younger people may develop BPPV as a consequence of head trauma. Women are twice as often affected as men.
Symptoms are brought on by specific movements of the head, particularly in the vertical plane (for example turning over in bed, looking upwards, or bending over).
Vertigo usually lasts a few seconds to a minute (typically less than 30 seconds). It is common for people to overestimate the duration of an episode.
Nausea is common, but vomiting is rare.
Light-headedness and imbalance are sometimes reported after the attack, and may last for several minutes or hours.
Hearing is not affected (although hearing impairment may coexist for a different reason).
Tinnitus is not a feature of benign paroxysmal positional vertigo.
Signs
Examination may be normal at rest in a sitting position. Spontaneous nystagmus or abnormalities of the ear on examination suggest an additional disorder.
The Hallpike manoeuvre should show nystagmus in posterior canal BPPV, usually after a latent period of a few seconds, which is torsional (rotatory) and beating towards the lowermost ear.
If nystagmus does not have these features, consider another diagnosis.
BPPV often has a relapsing and remitting course with long asymptomatic periods. Recovery with no treatment can occur spontaneously, although recurrence is common.
[Baloh et al, 1987; Lempert et al, 1995; Hanley et al, 2001; Parnes et al, 2003; Hilton and Pinder, 2004; Lempert and von Brevern, 2005; Bhattacharyya et al, 2008; Macleod and McAuley, 2008; Barraclough and Bronstein, 2009]
Features of vestibular neuronitis and labyrinthitis
How do I know my patient has vestibular neuronitis or labyrinthitis?
Vestibular neuronitis (more common) and labyrinthitis often affect previously well, young, or middle-aged adults.
In vestibular neuronitis, episodes may recur over 18 months, with reduction in the severity and length of successive attacks.
Symptoms
Vertigo occurs spontaneously, may develop on waking, or may develop over the course of the day. Acute symptoms usually settle in a few days because vestibular compensation occurs.
Nausea and vomiting occur, and balance may be affected. Gait apraxia is not a prominent feature.
Hearing loss is a feature of labyrinthitis, but hearing is not affected in vestibular neuronitis.
Tinnitus may also be a feature of labyrinthitis, but not vestibular neuronitis.
There are no focal neurological symptoms.
Signs
Nystagmus is present and is usually fine horizontal but may be mixed horizontal-torsional with the fast phase away from the affected ear. It always beats in the same direction, even if the head is rotated, and is reduced when the vision is fixed on a point.
The Head impulse test may be positive (but is less reliable than nystagmus as an examination finding, as it may also be positive for other peripheral causes of vertigo and so cannot be used to differentiate between them).
If corrective eye movements (saccades) occur after head movement in one direction, a peripheral vestibular lesion (of the labyrinth or 8th cranial nerve) affecting that side is likely. In normal people there are no saccades because their gaze remains fixed on the target.
[Hanley et al, 2001; Baloh, 2003; Hain and Uddin, 2003; Macleod and McAuley, 2008]
Features of Meniere's disease
How do I know my patient has Meniere's disease?
Meniere's disease usually occurs for the first time in people 20–50 years of age. Men are affected slightly more than women. There is often a family history.
Meniere's disease is commonly over-diagnosed.
Symptoms
Symptoms are episodic.
Vertigo is usually of spontaneous onset and lasts from around 20 minutes to 24 hours (usually 2–3 hours), rapidly increasing in intensity over the first few minutes. Bed rest is often needed.
Nausea and vomiting are common.
In addition, there are prodromal symptoms of fullness in the affected ear with a decrease in hearing and either the onset of, or a change in, tinnitus. Deafness and tinnitus can take a few days to resolve once the vertigo has settled. Deafness can be fluctuating and reversible in early cases, but is progressive if there are repeated episodes.
There are no central neurological symptoms.
Usually, one ear is affected, but occasionally the condition is bilateral.
Signs
There is no specific test for Meniere's disease.
Examination of hearing in established cases will commonly show a sensorineural deafness which can be confirmed on audiometry.
Nystagmus is always present during an attack and is usually mixed horizontal-torsional (rotatory) and beating away from the affected ear.
The clinical course of Meniere's disease can vary. There may be a cluster of attacks and long remissions.
[Hanley et al, 2001; Brandt and Strupp, 2003; Minor et al, 2004; Eggers, 2007; Macleod and McAuley, 2008; Sajjadi and Paparella, 2008]
Management
Management
Scenario : Benign paroxysmal positional vertigo: provides a link to the CKS topic on Benign paroxysmal positional vertigo for more information on management and referral.
Scenario : Vestibular neuronitis: provides a link to the CKS topic on Vestibular neuronitis for more information on management and referral.
Scenario : Labyrinthitis: covers the symptomatic management and referral of labyrinthitis.
Scenario : Meniere's disease: provides a link to the CKS topic on Meniere's disease for more information on management and referral.
Scenario : Central vertigo: covers the referral and initial symptomatic management of central causes of vertigo.
Scenario : Unknown cause: covers the management of vertigo when the cause is not known, including symptomatic treatment and referral.
Scenario : Benign paroxysmal positional vertigo
Scenario : Benign paroxysmal positional vertigo
Management
How should I manage benign paroxysmal positional vertigo?
Benign paroxysmal positional vertigo can usually be managed with advice and repositioning manoeuvres in primary care.
For more information on management and referral, see the CKS topic on Benign paroxysmal positional vertigo.
Basis for recommendation
Basis for recommendation
The basis for the recommendations on management are discussed in the CKS topic on Benign paroxysmal positional vertigo.
Scenario : Vestibular neuronitis
Scenario : Vestibular neuronitis
Management
How should I manage vestibular neuronitis?
Vestibular neuronitis can usually be managed in primary care with advice, and sometimes short-term symptomatic drug treatment.
For more information on management and referral, see the CKS topic on Vestibular neuronitis.
Basis for recommendation
Basis for recommendation
The basis for the recommendations on management are discussed in the CKS topic on Vestibular neuronitis.
Scenario : Labyrinthitis
Scenario : Labyrinthitis
Management
How should I manage labyrinthitis?
If labyrinthitis is suspected, admit the person to hospital or refer as an emergency to an ear, nose, and throat specialist or audiovestibular physician.
Basis for recommendation
Basis for recommendation
This recommendation is based on the opinion of CKS expert reviewers. They suggest that sudden-onset unilateral deafness (as found in labyrinthitis) can indicate acute ischaemia of the labyrinth or brainstem (but can also occur with infection or inflammation). Emergency treatment may restore hearing, so the person should be seen within 12 hours of the onset of symptoms.
Scenario : Meniere's disease
Scenario : Meniere's disease
Management
How should I manage Meniere's disease?
If Meniere's disease is suspected, refer the person to a balance specialist (ear, nose, and throat specialist or audiovestibular specialist — depending on local protocol) for confirmation of the diagnosis and further treatment.
For more details on management whilst the person is awaiting referral, see the CKS topic on Meniere's disease.
Basis for recommendation
Basis for recommendation
This recommendation is based on:
Referral criteria formulated from expert opinion for a study of referral patterns for dizziness in primary care. The referral criteria suggest that people with vertigo symptoms associated with tinnitus should be referred to an ear, nose, and throat specialist [Bird et al, 1998].
The opinion of CKS expert reviewers who suggest that referral should also be made if the person experiences vertigo with hearing loss or aural pressure, and that referral to a balance specialist allows the person to be seen by the specialist with the most relevant expertise.
Scenario : Central vertigo
Scenario : Central vertigo
Management
How should I manage central vertigo?
If a central cause of vertigo is suspected, admit the person to hospital or urgently refer to a balance specialist (neurologist or audiovestibular physician).
The urgency of referral depends on the severity of symptoms and the suspected diagnosis.
Admit the person if they have severe nausea and vomiting and are unable to tolerate oral fluids or symptomatic drug treatment.
People with known migrainous vertigo can be managed at home. However, admit or refer people with suspected migrainous vertigo for investigation to confirm the diagnosis.
Consider providing symptomatic drug treatment while the person is waiting to be admitted or seen by a specialist.
If the person's symptoms deteriorate and they have not yet been seen by a specialist, seek specialist advice.
Basis for recommendation
Basis for recommendation
Referral recommendations
These recommendations are based on referral criteria formulated from expert opinion for a study of referral patterns for dizziness in primary care [Bird et al, 1998]. These state that if a central neurological disorder is suspected, the person should be referred immediately. CKS expert reviewers suggested that immediate referral may not always be necessary for a person with migrainous vertigo.
The recommendation to refer people with a suspected central cause of vertigo is also based on what CKS considers to be good clinical practice. Some diagnoses of central vertigo (for example stroke) are medical emergencies.
Migrainous vertigo
Some experts suggest that migrainous vertigo can be treated with vestibular suppressants and treatments similar to those for standard migraine (such as triptans for acute attacks and prophylaxis) [Hain and Uddin, 2003; Lempert and von Brevern, 2005]. However, the diagnosis should be made cautiously, particularly in primary care, as brainstem vascular events can present in a similar way.
Other experts suggest that most people with new-onset headache and vertigo will need admission to hospital, unless there is a history of recurrent similar episodes, to exclude other potentially more serious diagnoses [Seemungal and Bronstein, 2008; Barraclough and Bronstein, 2009].
Symptomatic drug treatment
How should I treat the symptom of vertigo?
Consider offering symptomatic treatment prior to admission or while the person is waiting to see a specialist, but do not let this delay referral.
To rapidly relieve severe nausea or vomiting associated with vertigo, consider giving buccal prochlorperazine, or a deep intramuscular injection of prochlorperazine.
To alleviate less severe nausea, vomiting, and vertigo, consider prescribing a short course of:
Prochlorperazine (the buccal preparation has a faster onset of action than standard-release oral tablets), or cinnarizine, cyclizine, or promethazine teoclate (antihistamines).
Prochlorperazine is less sedating than the recommended antihistamines, but may cause a dystonic reaction (particularly in young women).
For more information, see Prescribing information.
Basis for recommendation
Basis for recommendation
Choice of drug treatment
CKS found no good quality evidence of benefit for the different symptomatic treatment options. However, these drugs are all licensed for nausea, vomiting, and vertigo [ABPI Medicines Compendium, 2007; ABPI Medicines Compendium, 2009a; ABPI Medicines Compendium, 2009b; ABPI Medicines Compendium, 2010a; ABPI Medicines Compendium, 2010c].
Duration of drug treatment
Expert opinion in narrative reviews suggests that symptomatic drug treatment should only be used in the short term, because prolonged use may delay vestibular compensation [Hanley et al, 2001; Macleod and McAuley, 2008]. The opinion of CKS expert reviewers was consistent with this.
Scenario : Unknown cause
Scenario : Unknown cause of vertigo
Managing vertigo with unknown cause
How should I manage peripheral vertigo of unknown cause?
Assess the person's symptoms, medical history, and clinical findings (see Determining the cause of vertigo).
If the person has:
Severe nausea and vomiting and is unable to tolerate oral fluids or symptomatic drug treatment — admit them to hospital.
Very sudden onset of vertigo (within seconds) that is not provoked by positional change and is persistent — admit or urgently refer the person to a neurologist or balance specialist (depending on local availability — for example ear, nose, and throat specialist, audiovestibular specialist, or care of the elderly physician with a special interest).
Central neurological symptoms or signs (for example new type of headache [especially occipital], gait disturbance, truncal ataxia) — admit or urgently refer the person to a neurologist.
Acute deafness without other typical features of Meniere's disease — admit or urgently refer the person to an ear, nose, and throat specialist or audiovestibular physician.
For all other people with vertigo of undetermined cause — refer to a balance specialist (ear, nose, and throat specialist, audiovestibular physician, neurologist, or care of the elderly physician with a special interest — depending on local protocol). The urgency of referral will depend on the person's symptoms, clinical findings, and clinical judgement.
While awaiting referral:
Consider offering symptomatic drug treatment with prochlorperazine or cinnarizine, cyclizine, or promethazine (antihistamines) for no longer than 1 week. It is important that the person stops symptomatic treatment 48 hours before seeing a specialist.
If the person's symptoms deteriorate, seek specialist advice.
Advise on safety issues.
Advise the person not to drive when they are dizzy, or if they are likely to experience an episode of vertigo while driving.
The Driver and Vehicle Licensing Agency state that people liable to 'sudden attacks of unprovoked or unprecipitated disabling giddiness' should stop driving.
For detailed guidance, see the At-a-Glance Guide to the Current Medical Standards of Fitness to Drive.
Workplace — the person should inform their employer if their vertigo poses a risk in the workplace (for example people using ladders, operating heavy machinery, or driving).
Falls in the home — discuss the risk of falling in the home during an episode of vertigo and suggest measures to reduce this.
Basis for recommendation
Basis for recommendation
These recommendations are based on expert opinion from:
A review article on the diagnosis of vertigo in general practice [Barraclough and Bronstein, 2009].
A review article which described criteria for urgent referral for neuroimaging [Kuo et al, 2008b].
A study reporting referral patterns for dizziness in primary care [Bird et al, 1998]. Referral criteria were formulated from expert opinion for this study.
CKS expert reviewers.
Symptomatic drug treatment
How should I treat the symptom of vertigo?
Consider offering symptomatic treatment prior to admission or while the person is waiting to see a specialist but do not let this delay referral.
To rapidly relieve severe nausea or vomiting associated with vertigo, consider giving buccal prochlorperazine, or a deep intramuscular injection of prochlorperazine.
To alleviate less severe nausea, vomiting, and vertigo, consider prescribing a short course of:
Prochlorperazine (the buccal preparation has a faster onset of action than standard-release oral tablets), or cinnarizine, cyclizine, or promethazine teoclate (antihistamines).
Prochlorperazine is less sedating than the recommended antihistamines, but may cause a dystonic reaction (particularly in young women).
For more information, see Prescribing information.
Benzodiazepines are not recommended.
Basis for recommendation
Basis for recommendation
Choice of drug treatment
CKS found no good quality evidence of benefit for the different symptomatic treatment options. However, these drugs are all licensed for use in people with labyrinthine disorders, and for nausea, vomiting, and vertigo [ABPI Medicines Compendium, 2007; ABPI Medicines Compendium, 2009a; ABPI Medicines Compendium, 2009b; ABPI Medicines Compendium, 2010a; ABPI Medicines Compendium, 2010c].
Duration of drug treatment
Expert opinion in review articles suggests that symptomatic drug treatment should only be used in the short term, because prolonged use may delay vestibular compensation [Hanley et al, 2001; Macleod and McAuley, 2008]. The opinion of CKS expert reviewers was consistent with this.
Benzodiazepines
Benzodiazepines are not recommended because although some experts advocate their use, CKS found no evidence to support this. They are not licensed for this purpose, and they have the potential for dependence [BNF 58, 2009].
Important aspects of prescribing information relevant to primary healthcare are covered in this section specifically for the drugs recommended in this CKS topic. For further information on contraindications, cautions, drug interactions, and adverse effects, see the electronic Medicines Compendium (eMC) (http://medicines.org.uk/emc), or the British National Formulary (BNF) (www.bnf.org).
Prochlorperazine
Prochlorperazine
Prescribing issues
What issues should I consider before prescribing prochlorperazine?
Do not give prochlorperazine to people with:
Parkinson's disease — prochlorperazine can cause drug-induced Parkinsonism and other extrapyramidal adverse effects.
Arrhythmias, hypokalaemia, or those taking other drugs known to prolong the QT interval — prochlorperazine has the potential to increase the QT interval. Use a sedating antihistamine instead.
Use prochlorperazine with caution (use a low dose and monitor adverse effects) in people with:
Liver or kidney dysfunction.
Cardiovascular disease (check serum electrolytes and electrocardiogram [ECG] before starting treatment).
Prostatic hypertrophy, narrow-angle glaucoma.
Epilepsy or a history of seizures — prochlorperazine can lower the seizure threshold.
In addition:
For pregnant women, cyclizine or promethazine are preferred (off-label use). There are fewer safety data on the use of prochlorperazine in pregnancy (off-label use), but it is also considered suitable [NTIS, 1999].
For women who are breastfeeding, phenothiazines are minimally excreted in breast milk, so occasional, short-term use of prochlorperazine is unlikely to affect the infant [LactMed, 2009].
If possible, check electrolytes and obtain an ECG before starting treatment, to rule out a predisposition towards ventricular arrhythmias.
The most commonly reported adverse effects are nervous system disorders.
Elderly people are particularly susceptible (and so lower doses are recommended), although some adverse events only occur with prolonged use (for example drug-induced Parkinsonism adverse effects such as tremor).
Acute dystonia and dyskinesia are usually transitory, are more common in children and young adults, and usually occur within the first 4 days of treatment.
Prochlorperazine may cause drowsiness; but it is less sedating that cinnarizine, cyclizine, and promethazine teoclate.
Anticholinergic adverse effects may also occur (for example blurred vision and dry mouth). Elderly people are particularly susceptible to antimuscarinic adverse effects (but they are not common).
Prochlorperazine may cause postural hypotension (especially in elderly people, and in those requiring deep intramuscular injection of prochlorperazine).
Prochlorperazine should be discontinued in people with an unexplained fever as this may be a sign of neuroleptic malignant syndrome (NMS). NMS is rare, but life-threatening. Other signs of NMS include rigidity, autonomic instability, labile blood pressure, tachycardia, sweating, incontinence, flushing, pallor, and altered level of consciousness.
[ABPI Medicines Compendium, 2007; ABPI Medicines Compendium, 2010b]
Advice for patients
What advice should I give to patients about prochlorperazine?
Advise people that:
Prochlorperazine may cause drowsiness and affect their ability to drive or operate machinery. Alcohol should be avoided while taking prochlorperazine (otherwise drowsiness will be potentiated).
High doses may cause a sensitivity to sunlight. If this occurs, sun lamps and direct sunlight should be avoided.
Prochlorperazine may affect how the body responds to environmental temperatures. Elderly people (especially) should consider their body temperature in very hot or very cold weather.
People should inform their doctor immediately if they have any of the following:
Fainting or dizziness on standing or sitting up.
Inability to control certain muscles, especially within the first 4 days of treatment or after an increase in dose. This may affect the tongue, mouth, arms, and legs; it is more common in young people.
Heart palpitations (unusually rapid or irregular heart beat).
Unexpected sore throat, infection, or fever.
Very slow, shallow breathing.
Advise people to stop taking their medicine and seek immediate medical advice if they develop:
A yellow tinge of the skin or eyes (jaundice).
A combination of high temperature, sweating, pale complexion, difficulty in passing urine, muscle stiffness, altered level of alertness (indicating neuroleptic malignant syndrome — rare, but life-threatening).
[ABPI Medicines Compendium, 2007; ABPI Medicines Compendium, 2010b]
Sedating antihistamines
What issues should I be aware of before prescribing sedating antihistamines for vertigo?
Prescribing issues
What issues should I consider before prescribing a sedating antihistamine?
Sedating antihistamines should be used with caution in people with:
Liver or kidney dysfunction.
Urinary retention, prostatic hypertrophy, angle-closure glaucoma, or pyloroduodenal obstruction — if possible, avoid using sedating antihistamines because of their significant antimuscarinic activity (particularly in elderly people).
Epilepsy — avoid antihistamines if possible, as they reduce the seizure threshold.
In addition:
People with severe heart failure: avoid using cyclizine if possible, as it may decrease cardiac output.
People with Parkinson's disease: avoid using cinnarizine if possible, as there have been rare reports of cinnarizine-induced Parkinsonism [Micromedex, 2007].
Pregnant women: cyclizine or promethazine teoclate are both considered to be suitable for use during pregnancy (off-label use). No increase in birth defects after clinical use of cinnarizine have been shown but in the absence of controlled studies, cinnarizine should not be routinely used in pregnancy [NTIS, 2002; Schaefer et al, 2007].
Women who are breastfeeding: do not use sedating antihistamines. There are no data on whether cinnarizine, cyclizine, or promethazine are excreted in breast milk. Other sedating antihistamines (such as chlorphenamine) that are known to be excreted in breast milk cause sedation and poor feeding in the infant [Trent Drug Information Service, 2001].
The most commonly reported adverse effects are nervous system disorders.
Elderly people are particularly susceptible (and so lower doses are recommended).
Sedating antihistamines may cause drowsiness.
Anticholinergic adverse effects may also occur (for example blurred vision and dry mouth).
Extrapyramidal symptoms are rare but have been reported with cinnarizine. At most risk are elderly people receiving prolonged treatment.
Cyclizine is a recognized substance of misuse for its euphoric or hallucinatory effects and extra vigilance is needed when prescribing it [RPSGB, 2006].
[ABPI Medicines Compendium, 2009a; ABPI Medicines Compendium, 2009b; ABPI Medicines Compendium, 2010a]
Advice for patients
What advice should I give to patients about sedating antihistamines?
Advise people that:
Sedating antihistamines may cause drowsiness. The degree of sedation will vary between individuals and will depend on the dose given, but if affected the person should avoid driving or performing skilled tasks. Alcohol should be avoided while taking prochlorperazine otherwise drowsiness will be potentiated.
Cinnarizine may cause gastrointestinal irritation; but this is usually transient and can be minimized by taking it with or after food.
Evidence
Evidence
Supporting evidence
This section summarizes the evidence that supports the recommendations on the primary care treatment of vertigo caused by benign paroxysmal positional vertigo or vestibular neuronitis.
Evidence for the primary care treatment of Meniere's disease is covered in the section on Supporting evidence in the CKS topic on Meniere's disease.
The Epley manoeuvre
Evidence on the Epley manoeuvre for benign paroxysmal positional vertigo
Low-quality evidence suggests that the Epley manoeuvre is more effective for treating benign paroxysmal positional vertigo (BPPV) than sham manoeuvres or no treatment in the short term (up to 1 month). The effectiveness of the Epley manoeuvre over longer time periods, or compared with other active treatments for BPPV, is unclear.
A Cochrane systematic review of the Epley manoeuvre for benign paroxysmal positional vertigo [Hilton and Pinder, 2004] (last assessed as up to date following a subsequent search in July 2006) found 16 trials, of which three (involving 144 people) were considered suitable for inclusion.
Two trials compared the Epley manoeuvre with a sham manoeuvre, and the other compared the Epley manoeuvre with no treatment. No comparisons between the Epley manoeuvre and other active treatments for posterior canal BPPV were found. In all three studies, no premedication was used, and no mastoid vibration was applied. Post-treatment instructions were very similar. Follow up was from 1 week to 1 month after treatment. Outcomes were resolution of symptoms and conversion from positive to negative Dix–Hallpike test. There were methodological limitations to all trials (such as lack of long-term follow up, and poor randomization in two of the trials).
In terms of symptom improvement, a statistically significant difference in symptom resolution was found, with treatment (Epley manoeuvre) being more effective than sham manoeuvre or no treatment. When data were pooled, the odds ratio was 4.22 (95% CI 1.96 to 9.08).
In terms of achieving a negative Hallpike manoeuvre when the previous manoeuvre had been positive, treatment was found to be more effective than sham manoeuvre or no treatment. When data were pooled, the odds ratio was 5.12 (95% CI 2.30 to 11.38).
The data were not sufficient to compare the Epley manoeuvre with other active treatments for BPPV.
Adverse effects were rare. Vomiting was reported during the treatment, and for some people the positions were not tolerated because of cervical spine problems. However, no serious complications were reported.
Vestibular rehabilitation
Evidence on vestibular rehabilitation for peripheral vestibular dysfunction
Low quality evidence suggests that vestibular rehabilitation (exercises to promote central nervous system compensation) is effective at reducing dizziness and other symptoms (such as balance and gait). However, results were mainly from single studies with significant heterogeneity.
A Cochrane systematic review (search date: March 2007) identified 21 trials on the use of vestibular rehabilitation in adults for unilateral peripheral vestibular dysfunction caused by benign paroxysmal positional vertigo (BPPV), vestibular neuritis, labyrinthitis, Meniere's disease, or surgery [Hillier and Holohan, 2007].
There was variation between studies in terms of the vestibular rehabilitation method used, and whether vestibular rehabilitation was compared with placebo, another vestibular rehabilitation manoeuvre, or another management intervention (for example drugs, or passive manoeuvres). Different outcome measures were also used.
Data from three similar studies were pooled — vestibular rehabilitation was found to be more effective than sham interventions or control in terms of dizziness.
Single studies found that vestibular rehabilitation was effective at improving other parameters (such as balance, vision, and gait).
Studies in which people were followed up showed a positive effect for 3–12 months.
Evidence was insufficient to determine which form of vestibular rehabilitation is more effective. However, evidence specifically in people with BPPV suggests that physical repositioning manoeuvres are more effective than vestibular rehabilitation at reducing dizziness.
Search strategy
Scope of search
A literature search was conducted for guidelines, systematic reviews and randomized controlled trials on primary care management of Vertigo with additional searches for evidence in the following areas:
Prochlorperazine, antihistamines, cyclizine, cinnarizine, betahistine
Salt restrictions
Labyrinthitis, Meniere's disease, vestibular neuritis, vestibular neuronitis vestibulopathy, neurolabyrinthitis, acute unilateral peripheral vestibulopathy
Brandt–Daroff exercises
The search excluded pregnant women, children and immunocompromised patients.
Search dates
January 1999 – November 2009
Key search terms
Various combinations of searches were carried out. The terms listed below are the core search terms that were used for Medline and these were adapted for other databases. Further details are available on request.
vertigo/, vertigo.tw.,
vestibular neuritis.tw., benign paroxysmal positional.tw., BP$V.tw., acoustic neuroma/, motion sickness.tw., meniere disease/, meniere's disease.tw., labyrinthitis/, labyrinthitis.tw., vestibular neuronitis.tw., vestibular neuronitis/, vestibulopathy.tw., neurolabyrinthitis.tw., acute unilateral peripheral vestibulopathy.tw.
betahistine/, betahistine.tw., prochlorperazine/, prochlorperazine.tw., antihistamine/, antihistamines.tw., cyclizine/, cyclizine.tw., cinnarizine/, cinnarizine.tw., promethazine/, promethazine.tw.
Brandt-Daroff.tw.
Table 1. Key to search terms.| Search commands | Explanation |
|---|---|
| / | indicates a MeSh subject heading with all subheadings selected |
| .tw | indicates a search for a term in the title or abstract |
| exp | indicates that the MeSH subject heading was exploded to include the narrower, more specific terms beneath it in the MeSH tree |
| $ | indicates that the search term was truncated (e.g. wart$ searches for wart and warts) |
Sources of guidelines
National Institute for Health and Clinical Excellence (NICE)
Scottish Intercollegiate Guidelines Network (SIGN)
National Guidelines Clearinghouse
British Columbia Medical Association
Institute for Clinical Systems Improvement
Guidelines International Network
National Library of Guidelines
National Health and Medical Research Council (Australia)
University of Michigan Medical School
Michigan Quality Improvement Consortium
National Resource for Infection Control
NHS Scotland National Patient Pathways
Agency for Healthcare Research and Quality
UK Ambulance Service Clinical Practice Guidelines
RefHELP NHS Lothian Referral Guidelines
Medline (with guideline filter)
Sources of systematic reviews and meta-analyses
Systematic reviews
Protocols
Database of Abstracts of Reviews of Effects
Medline (with systematic review filter)
EMBASE (with systematic review filter)
Sources of health technology assessments and economic appraisals
NIHR Health Technology Assessment programme
NHS Economic Evaluations
Health Technology Assessments
Canadian Agency for Drugs and Technologies in Health
International Network of Agencies for Health Technology Assessment
Sources of randomized controlled trials
Central Register of Controlled Trials
Medline (with randomized controlled trial filter)
EMBASE (with randomized controlled trial filter)
Sources of evidence based reviews and evidence summaries
DynaMed
Central Services Agency COMPASS Therapeutic Notes
Sources of national policy
References
ABPI Medicines Compendium (2007) Summary of product characteristics for Stemetil tablets 5mg. Electronic Medicines Compendium..Datapharm Communications Ltd.www.medicines.org.uk [Free Full-text]
ABPI Medicines Compendium (2009a) Summary of product characteristics for Avomine tablets 25mg. Electronic Medicines Compendium..Datapharm Communications Ltd.www.medicines.org.uk
ABPI Medicines Compendium (2009b) Summary of product characteristics for Valoid tablets. Electronic Medicines Compendium..Datapharm Communications Ltd.www.medicines.org.uk [Free Full-text]
ABPI Medicines Compendium (2010a) Summary of product characteristics for Stugeron 15mg. Electronic Medicines Compendium..Datapharm Communications Ltd.www.medicines.org.uk [Free Full-text]
ABPI Medicines Compendium (2010b) Summary of product characteristics for Stemetil injection. Electronic Medicines Compendium..Datapharm Communications Ltd.www.medicines.org.uk [Free Full-text]
ABPI Medicines Compendium (2010c) Summary of product characteristics for Buccastem 3mg. Electronic Medicines Compendium..Datapharm Communications Ltd.www.medicines.org.uk [Free Full-text]
Baloh, R.W. (2003) Clinical practice. Vestibular neuritis. New England Journal of Medicine 348(11), 1027-1032.
Baloh, R.W., Honrubia, V. and Jacobson, K. (1987) Benign positional vertigo: clinical and oculographic features in 240 cases.. Neurology 37(3), 371-378. [Abstract]
Barraclough, K. and Bronstein, A. (2009) Vertigo. BMJ 339, b3493.
Bhattacharyya, N., Baugh, R.F., Orvidas, L. et al. (2008) Clinical practice guideline: benign paroxysmal positional vertigo. Otolaryngology - Head and Neck Surgery 139(5 Suppl 4), S47-S81. [Abstract]
Bird, J.C., Beynon, G.J., Prevost, A.T. and Baguley, D.M. (1998) An analysis of referral patterns for dizziness in the primary care setting. British Journal of General Practice 48(437), 1828-1832. [Abstract] [Free Full-text]
BNF 58 (2009) British National Formulary. 58th edn. London: British Medical Association and Royal Pharmaceutical Society of Great Britain.
Brandt, T. and Strupp, M. (2003)
Douglas, G., Nicol, F. and Robertson, C. (Eds.) (2009) Macleod's clinical examination. 12th edn. Edinburgh: Churchill Livingstone Elsevier.
Eggers, S.D. (2007) Migraine-related vertigo: diagnosis and treatment. Current Pain and Headache Reports 11(3), 217-26. [Abstract]
Evans, J.G. (1990) Transient neurological dysfunction and risk of stroke in an elderly British population: the different significance of vertigo and non-rotatory dizziness. Age and Ageing 19(1), 43-49. [Abstract]
Hain, T.C. and Uddin, M. (2003) Pharmacological treatment of vertigo. CNS Drugs 17(2), 85-100. [Abstract]
Hanley, K. and O'Dowd, T. (2002) Symptoms of vertigo in general practice: a prospective study of diagnosis. British Journal of General Practice 52(483), 809-812. [Free Full-text]
Hanley, K., O'Dowd, T. and Considine, N. (2001) A systematic review of vertigo in primary care. British Journal of General Practice. 51(469), 666-671. [Free Full-text]
Hillier, S.L. and Holohan, V. (2007) Vestibular rehabilitation for unilateral peripheral vestibular dysfunction (Cochrane Review). The Cochrane Library.Issue 4.John Wiley & Sons, Ltd.www.thecochranelibrary.com [Free Full-text]
Hilton, M.P and Pinder, D.K (2004) The Epley (canalith repositioning) manoeuvre for benign paroxysmal positional vertigo (Cochrane Review). The Cochrane Library.Issue 2.John Wiley & Sons, Ltd.www.thecochranelibrary.com [Free Full-text]
Kuo, C-H., Pang, L. and Chang, R. (2008a) Vertigo: part 2 - management in general practice. Australian Family Physician 37(6), 409-413. [Free Full-text]
Kuo, C-H, , Pang, L. and Chang, R. (2008b) Vertigo: part 1 - assessment in general practice. Australian Family Physician 37(5), 341-347. [Free Full-text]
LactMed (2009) Prochlorperazine. ..National Library of Medicine.www.toxnet.nlm.nih.gov
Lempert, T. and von Brevern, M. (2005) Episodic vertigo. Current Opinion in Neurology 18(1), 5-9. [Abstract]
Lempert, T., Gresty, M.A. and Bronstein, A.M. (1995) Fortnightly review: benign positional vertigo: recognition and treatment. British Medical Journal 311(7003), 489-491. [Free Full-text]
Macleod, D. and McAuley, D. (2008) Vertigo: clinical assessment and diagnosis. British Journal of Hospital Medicine 69(6), 330-334. [Abstract]
Micromedex (2007) MICROMEDEX [CD-ROM].(Vol 131, 1st quarter 2007).Thomson Healthcare.
Minor, L.B., Schessel, D.A. and Carey, J.P. (2004) Meniere's disease. Current Opinion in Neurology 17(1), 9-16. [Abstract]
Munro, J. (Ed.) (1995) Macleod's clinical examination. 9th edn. Edinburgh: Churchill Livingstone.
NTIS (1999) Nausea and vomiting in pregnancy. ..Newcastle upon Tyne: National Teratology Information Service, Regional Drug and Therapeutics Centre.
NTIS (2002) Promethazine exposure during pregnancy. Newcastle upon Tyne: National Teratology Information Service, Regional Drug and Therapeutics Centre.
Parnes, L.S., Agrawal, S.K. and Atlas, J. (2003) Diagnosis and management of benign paroxysmal positional vertigo (BPPV). CMAJ 169(7), 681-693. [Abstract] [Free Full-text]
RPSGB (2006) Substances of misuse. ..Royal Pharmaceutical Society of Great Britain.
Sajjadi, H. and Paparella, M.M. (2008) Meniere's disease. Lancet 372(9636), 406-414. [Abstract]
Schaefer, C., Peters, P. and Miller, R.K. (Eds.) (2007) Drugs during pregnancy and lactation: treatment options and risk assessment. 2nd edn. Oxford: Academic Press.
Seemungal, B.M. and Bronstein, A.M. (2008) A practical approach to acute vertigo. Practical Neurology 8(4), 211-221. [Abstract]
Swartz, R. and Longwell, P. (2005) Treatment of vertigo. American Family Physician 71(6), 1115-1122. [Abstract] [Free Full-text]
Trent Drug Information Service (2001) Drugs in breast milk: quick reference guide. UKMiCentral...www.ukmicentral.nhs.uk