Key references discussed in the episode:
Useful YouTube links:
Key take-home points from the episode:
- 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.
- 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.
- 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.
- 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.
- 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%.
- 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.
- Headache may or may not be present in vestibular migraine
- There is no high-quality evidence to support the use of betahistine for vertigo in Meniere’s disease.
- 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.
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