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DIZZINESS AND VERTIGO

Extracted from Dizziness and Vertigo, a guide for General Practitioners
Professor Dr. W.J. Oosterveld The Hague

DEFINITION
Vertigo is a sensation as if the external world is revolving around the patient or as if (s)he him/herself is revolving in space. Dizziness is a disturbed sense of relationship to space, it is a sensation of unsteadiness with a feeling of movement with the head, giddiness. It is not possible to give a much more accurate description, as each patient suffering from dizziness will give a different description of the complaint.

Patients use terms such as spinning sensation, giddiness, light headedness, dizzy spells or a feeling of unsteadiness. Vertigo and dizziness are only symptoms. It is never a syndrome, any more than a fever or headache are.

FORMS AND CAUSES
On the basis of the history, five main forms can be differentiated, while on the basis of test results it can also be decided whether the underlying disorder is of a possible severe character - in other words, whether the GP can treat the problem or whether the patient must be referred on for further diagnosis.

These five main forms are :

1. Paroxysmal vertigo: the sudden attack which comes on quickly, lasts only a short time (from seconds to a few hours) and then goes away again just as quickly. Recurs after symptom-free intervals.
2. The sudden, intense attack, fading away much more slowly than the first type: it takes days and even weeks to disappear completely.
3. Chronic vertigo: often not serious but - with small flare ups - permanently present. Lasts for months without any change.
4. Positioning vertigo: occurs following sudden movements of the head, often in one particular plane.
5. Dizziness spells: lasting a few seconds, occurring irregularly.

Almost 100 different syndromes can be accompanied by vertigo. In many cases, it is not possible to specify one particular type of vertigo which is specific to a syndrome.

FORM 1: PAROXYSMAL VERTIGO
The sudden attack which goes away again quickly generally has two causes which are not straight forward: vertebrobasilar insufficiency and cervical vertigo.

On the other hand, these are disorders which can be detected very well at the outset and treated: benign paroxysmal positional vertigo (BBPV), orthostatic vertigo, and hyperventilation. And then there are disorders requiring assessment by a medical specialist: Ménière's disease (audiological examination compulsory), hypoglycaemia and syncope.

FORM 2: SINGLE ATTACK OF VERTIGO
The severe attack which does not go away quickly, but only diminishes slowly in the course of days or weeks, may be a symptom of vestibular neuritis which practically always disappears spontaneously and without after-effect. It is therefore not severe.

A unilateral, acute labyrinthine outburst can sometimes already be apparent from the history, but has to be proved.

Occasionally, this type also occurs with multiple sclerosis (MS), especially at the start of the illness; this, like labyrinthine vascular accidents, (peri)labyrinthitis, and herpes zoster oticus, has to be referred to a specialist.

FORM 3: CHRONIC VERTIGO
Chronic vertigo is seen quite often in association with atherosclerosis cerebri. Whether one still decides to refer such a patient to a specialist will thus depend how well one knows one's patient. This applies almost equally in the case of hypertension. Chronic vertigo can sometimes occur with chronic otitis, where it may have a nagging character and be intensified by movements.

Chronic vertigo may also point to a serious disorder of the central nervous system. Post-traumatic vertigo is also sometimes chronic in nature.

FORM 4: POSITIONING VERTIGO
This vertigo occurs when turning to a particular posture. An important example of this is BPPV. Where positioning vertigo continues in a certain position, one talks of "positional vertigo". Persistent positional vertigo requires further investigation because it can be a symptom of a cerebellar disorder.

FORM 5: DIZZINESS SPELLS
Dizziness spells can occur at any age, but are nevertheless more prevalent among older people.

The causes can vary considerably, but are basically due to cardiovascular factors and hyper- or hypotension.

With vertigo a specialist examination is desirable in the following circumstances:

SPECIALIST EXAMINATION IN THE CASE OF VERTIGO
Serious vertigo which is disabling.

1. Vertigo lasting longer than 4 weeks.
2. Vestibular disorders, whether or not accompanied by vertigo.
3. Changes in hearing performance.
4. Nystagmus, or other abnormal eye movements.

SYNDROMES

A few syndromes in which vertigo is an important symptom:

BENIGN PAROXYSMAL POSITIONAL VERTIGO
Dizziness occurring when a person lies down, often when the head or body is held in a particular way. The dizziness appears after a latent period of a few seconds, lasts no more than 30 seconds and quickly passes. This provocation is self-limiting. The cause of the syndrome is not known. Treatment consists of adaptation exercises. .. further information

MENIERE'S SYNDROME
Attacks of vertigo lasting minutes to hours, accompanied by vegetative symptoms such as tinnitus in one ear and varying but gradually worrying hearing loss in that ear.

The syndrome occurs with various internal disorders, and also as an independent disorder, when it is called Ménière's disease.

The cause is unclear.

The treatment consists of pharmacotherapy with anti-vertigo drugs.

HYPERVENTILATION
Over-active respiration can cause reduced carbon dioxide tension in the blood, which can lead to cerebral ischaemia. This can manifest itself in visual disturbances and changes in consciousness. Dizziness in the form of giddiness is often reported. Anxiety, tachycardia and tetany symptoms in the hands and fingers are found in this syndrome.

Hyperventilation sometimes also occurs as a result of stress situations. It is necessary to watch out for the latent form of this syndrome.

The treatment consists of counselling, the advice to breath into a bag in the event of an attack, and sometimes sedation.

JUVENILE VERTIGO
Vertigo in children involves the same syndromes as those found in older people. One particular form occurring in children between the ages of 4 and 14 is "juvenile vertigo". This involves attacks lasting a few minutes in which the main thing is anxiety. The syndrome always disappears again spontaneously within a few months.

The treatment consists of a low dose of antiepiletics where the frequency of the attacks is more than one a week..

SENILE VERTIGO
Vertigo often occurs in the elderly. Above the age of 65, half of all patients sometimes have trouble with dizziness. This can have various causes, though atherosclerosis cerebri certainly plays a big part.

Treatment actually consists solely of pharmacotherapy, though here it is important to avoid as far as possible drugs which cause drowsiness as a side effect.

VESTIBUALR NEURITIS
Acute vertigo with vegetative symptoms caused by viral inflammation of one vestibular nerve, mostly following infection of the upper respiratory tract. The vertigo subsides within the course of days to weeks. There are never any hearing problems.

The treatment is just wrapping up warm. In the case of severe vertigo, pharmacotherapy is given. The condition clears up spontaneously in 3 to 6 weeks.

MIGRAINE
Vertigo sometimes appears as a side effect of migraine. The diagnosis is clear from the prominent symptoms of migraine. Specific therapy to combat vertigo is necessary here in very exceptional cases only.

MOTION SICKNESS
A natural occurrence which practically everyone experiences at one time or another. It is a complex of symptoms in response to an unusual pattern of stimuli from the vestibular system. Vegetative symptoms with a strong feeling of being unwell are the most prominent symptoms. Motion sickness occurs more in children than in older people, and more in females than in males.

Prevention and treatment consists of anti-motion sickness drugs, the strongest active component of which is cinnarizine.