Vertigo

Overview

This Guidelines summary for GPs and pharmacists, of the NICE Clinical Knowledge Summary (CKS) on vertigo, covers the diagnosis, management, and treatment of vertigo in adults. It includes recommendations on diagnosing, assessing, and managing peripheral and central vertigo, and prescribing information.

For detailed information on specific clinical tests, and for information on adverse effects and drug interactions of cinnarizine, cyclizine, prochlorperazine, and promethazine teoclate, refer to the full CKS topic.

Reflecting on your Learnings

Reflection is important for continuous learning and development, and a critical part of the revalidation process for UK healthcare professionals. Click here to access the Guidelines Reflection Record.

Diagnosis

Confirming 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?'
• If the person has nystagmus it is likely that their dizziness is vertigo.

Assessment

• If a person presents with vertigo, ask about:
  • The vertigo
    • Timing of symptoms — duration, onset, frequency
    • Aggravating factors (such as movement of the head)
    • Severity and effect on daily activities (such as walking).
  • Associated symptoms
    • Nausea and vomiting
    • Otological — such as hearing loss, ear discharge, a feeling of fullness in the ear, or tinnitus
    • Neurological — such as headache, diplopia, visual disturbance, dysarthria or dysphagia, paraesthesia, muscle weakness, ataxia, migraine aura.
  • 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 vestibular neuronitis — may suggest benign paroxysmal positional vertigo (but trauma can also indicate a central cause)
    • Direct trauma to the ear or head trauma — consider perilymphatic fistula (but trauma can also indicate a central cause)
    • 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) — 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.
• When examining a person with vertigo:
  • Examine the ear — look for discharge, vesicular eruptions (indicating herpes zoster infection) and signs of cholesteatoma (for example a retraction pocket)
  • Perform a neurological examination:
    • Look at the person's face for signs of asymmetry suggestive of peripheral facial nerve involvement or a cerebrovascular event
    • Test cranial nerves and cerebellar function (for example heel to toe walking)
    • Examine the eyes for nystagmus — 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, coordination, and their ability to stand unaided. If symptoms are too severe to allow walking, ask the person to sit upright without holding on to anything.
  • Perform a cardiovascular examination (blood pressure, heart rate and rhythm, carotid examination for bruits)
  • Consider using 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)
    • Dix–Hallpike manoeuvre — (if the person has positional vertigo affected by moving the head) to help make a diagnosis of benign paroxysmal positional vertigo
    • Head impulse test — to detect unilateral hypofunction of the peripheral vestibular system, and to help differentiate between cerebellar infarction and vestibular neuronitis
    • Unterberger's test — to identify dysfunction of one of the labyrinths
    • Alternate cover test — an abnormal result suggests an increased likelihood of stroke in a person with acute vestibular syndrome.

For detailed information on each of the clinical tests mentioned, refer to the full CKS topic.

Determining the Cause

• Using findings from the history and examination, determine whether vertigo is likely to have a central or peripheral cause. 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:
  • Prolonged, severe vertigo (although this can also indicate vestibular neuronitis or Meniere's disease)
  • New-onset headache or recent trauma
  • Cardiovascular risk factors.
• Features suggestive of a peripheral cause of vertigo include:
  • A normal neurological examination
  • Severe nausea and vomiting
  • Hearing loss — generally found in people with inner ear pathology, but note that it can also occur in stroke or intracranial tumours.
• For more detail on differentiating features of peripheral and central vertigo, see Table 1.

Table 1: Summary of Clinical Features of Peripheral and Central Vertigo

• If a central cause of vertigo is suspected, see the section, Central Vertigo for more information on management
• If a peripheral cause of vertigo is suspected, use the history and examination findings to differentiate between conditions:
  • In benign paroxysmal positional vertigo (BPPV), episodes of vertigo are induced (rather than exacerbated) by moving the position of the head and episodes last for seconds (less than 1 minute). Typical findings are elicited with the Dix-Hallpike manoeuvre. The nystagmus of BPPV is torsional but not sustained. For more information, see the CKS topic on Benign paroxysmal positional vertigo
  • In vestibular neuronitis and labyrinthitis, vertigo is sudden in onset and severe. It usually persists for several days and gradually improves with time. The Head impulse test is positive
    • In vestibular neuronitis there is no hearing loss or tinnitus, but a spontaneous nystagmus may be present at the start of the episode
    • People with labyrinthitis report 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
    • For more information, see the CKS topic on Vestibular neuronitis.
  • In Meniere's disease, episodes of vertigo occur spontaneously, are not provoked by position change, and last much longer than in BPPV (30 minutes to several hours). Tinnitus, fluctuating hearing loss, and fullness in the ear are present in Meniere's disease, but not usually in BPPV or vestibular neuronitis. There is no specific test for Meniere's disease. For more information, see the CKS topic on Meniere's disease.
• If a peripheral cause is suspected but the underlying diagnosis remains in doubt, see the section, Peripheral Vertigo for more information on management.

Management

From age 18 years onwards.

Central Vertigo

• If a central cause of vertigo is suspected, admit the person to hospital or urgently refer to a balance specialist (such as a neurologist or audiovestibular physician, depending on local service provision). 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
  • Consider managing people with known migrainous vertigo at home. However, admit or refer people with suspected migrainous vertigo for investigation to confirm the diagnosis.
• Consider offering short-term symptomatic drug treatment while the person is waiting to be admitted or seen by a specialist, but do not allow this to delay referral
  • To rapidly relieve severe nausea or vomiting associated with vertigo, consider giving buccal prochlorperazine, or a deep intramuscular injection of prochlorperazine or cyclizine
  • To alleviate less severe nausea, vomiting, and vertigo, consider prescribing a short oral course of prochlorperazine, or cinnarizine, cyclizine, or promethazine teoclate (antihistamines)
  • For more information, see the section, Prescribing information.
• If the person's symptoms deteriorate and they have not yet been seen by a specialist, seek specialist advice. 

Peripheral Vertigo

• Assess the person's symptoms, medical history, and clinical findings. If the person has features suggestive of a particular cause of peripheral vertigo, manage appropriately. For more information, see the relevant CKS topics on Benign paroxysmal positional vertigo, Meniere's disease, and Vestibular neuronitis
• If a peripheral cause of vertigo is being considered, admit to hospital or urgently refer (using clinical judgement depending on type and severity of symptoms) to an appropriate specialist (depending on local service provision) if the person has:
  • Severe nausea and vomiting and is unable to tolerate oral fluids or symptomatic drug treatment 
  • Very sudden onset of vertigo (within seconds) that is not provoked by positional change and is persistent
  • Central neurological symptoms or signs (for example new type of headache [especially occipital], gait disturbance, truncal ataxia, vertical nystagmus)
  • Acute deafness without other typical features of Meniere's disease.
• 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 service provision). 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 teoclate (antihistamines) for no longer than 1 week
  • To rapidly relieve severe nausea or vomiting associated with vertigo, consider giving buccal prochlorperazine, or a deep intramuscular injection of prochlorperazine or cyclizine
  • To alleviate less severe nausea, vomiting, and vertigo, consider prescribing a short oral course of prochlorperazine, or cinnarizine, cyclizine, or promethazine teoclate (antihistamines).
• If the person's symptoms deteriorate, seek specialist advice.

Prescribing Information

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 related to the drugs mentioned in this section, see the electronic Medicines Compendium or the British National Formulary, and the full NICE CKS topic on vertigo.

Cinnarizine

Dosage

• For vestibular symptoms, prescribe oral cinnarizine 30 mg three times a day.

Contraindications and Cautions

• Do not prescribe cinnarizine if the person:
  • Is hypersensitive to cinnarizine or any of its excipients
  • Has porphyria
  • Has severe liver disease (there is an increased risk of coma).
• Prescribe cinnarizine with caution if the person has:
  • Parkinson’s disease – give only if the advantages outweigh the risk of disease exacerbation
  • Hepatic or renal impairment
  • Epilepsy
  • Prostatic hypertrophy
  • Pyloroduodenal obstruction
  • Susceptibility to angle closure glaucoma
  • Urinary retention.

Cyclizine

Dosage

• For nausea, vomiting, vertigo, or labyrinthine disorders, prescribe cyclizine 50 mg orally up to three times a day
• If the oral route is not appropriate, cyclizine 50 mg by intramuscular injection can be given up to three times a day.

Contraindications and Cautions

• Do not prescribe cyclizine to people with:
  • Hypersensitivity to cyclizine or its excipients
  • Severe liver disease — increased risk of coma
  • Porphyria.
• Prescribe cyclizine with caution to people with:
  • Prostatic hypertrophy, urinary retention, susceptibility to angle-closure glaucoma, and pyloroduodenal obstruction
  • Hepatic disease
  • Epilepsy
  • Severe heart failure or acute myocardial infarction — cyclizine may cause a fall in cardiac output associated with increases in heart rate, mean arterial pressure, and pulmonary wedge pressure
  • Phaeochromocytoma.

Prochlorperazine

Dosage

• For vertigo, prescribe prochlorperazine 5 mg orally three times a day (maximum dose 30 mg daily)
• If the oral route is not appropriate, consider prescribing either:
  • Prochlorperazine buccal tablets 3–6 mg twice a day (to be placed high in the buccal cavity and allowed to dissolve), or 
  • Prochlorperazine 12.5 mg by deep intramuscular injection followed by oral medication after an interval of 6 hours, if required.

Contraindications and Cautions

• Do not prescribe prochlorperazine to people with:
  • Hypersensitivity to prochlorperazine or its excipients
  • Agranulocytosis
  • A history of angle closure glaucoma
  • Prostate hypertrophy
  • Myasthenia gravis
  • Heart failure
  • Hypothyroidism
  • Parkinson's disease
  • History of jaundice
  • Liver or renal dysfunction
  • Phaeochromocytoma.
• Prescribe prochlorperazine with caution to:
  • People with epilepsy or a history of seizures — close monitoring is required in this group of people as prochlorperazine may lower the seizure threshold
  • Elderly people — use with caution, especially during very hot or cold weather due to the risk of hyper- or hypothermia
  • People with cardiovascular disease or family history of QT prolongation — cases of QT interval prolongation have been very rarely reported with prochlorperazine. An alternative anti-emetic should be considered for people with predisposing factors for ventricular arrhythmias, or they should be carefully monitored (check electrolytes and ECG), particularly during the initial phase of treatment.
    • Cardiac disease; metabolic abnormalities such as hypokalaemia, hypocalcaemia, or hypomagnesaemia; starvation; alcohol misuse; and concurrent treatment with other drugs known to prolong the QT interval may predispose people to ventricular arrhythmias.

Promethazine Teoclate

Dosage

• Prescribe promethazine teoclate 25 mg orally at night. The dose may be increased to 100 mg daily.

Contraindications and Cautions

• Promethazine teoclate should not be used in people with:
  • Hypersensitivity to promethazine, its excipients, or other phenothazines
  • Central nervous system (CNS) depression of any cause
  • Exposure to monoamine oxidase inhibitors within the previous 14 days
  • Severe liver disease — increased risk of coma.
• Promethazine teoclate should be used with caution in people with:
  • Hepatic or renal impairment
  • Severe coronary artery disease
  • Urinary retention or prostatic hypertrophy
  • Angle-closure glaucoma
  • Pyloroduodenal obstruction
  • Epilepsy
  • Asthma, bronchitis, or bronchiectasis — promethazine teoclate may thicken or dry lung secretions and impair expectoration.