Vertigo and dizziness

This summary provides information on how to treat patients with vertigo and dizziness in different situations and circumstances.

Please note this summary is only designed as a brief summary of management.

Dizziness is a very common symptom patients may experience and has varying levels of indicators, which are mostly benign. Patient history will help distinguish the cause, but patience and thorough examination are often required.

Dizziness can present itself in the following ways:

• Lightheadedness / presyncope: a feeling you might pass out.
• Dissociation: a spaced out feeling as if disconnected from your body or the world around you.

Vertigo – the illusion of movement

Vertigo arises from lesions of either the inner ear (vestibular apparatus) or the brain, although the former is far more common.

• Benign paroxysmal positional vertigo (BPPV): short lasting (seconds) bursts of vertigo with movement, typically rolling over in bed, getting in and out of bed, chairs, car, looking up at cupboards, hanging up washing. It is common after head injury and under-recognised, but is highly treatable without drugs. 
• Vestibular migraine: the only common brain cause of vertigo. Attacks can last from a few hours to several day. This is usually associated with other migrainous features, but not always headache.
• Acute vestibular syndrome (aka labyrinthitis, vestibulo-neuronitis): typically disabling vertigo lasts a few days. Most people recover fully, but it can occasionally recur and/or leads to PPPD (see below).
• Persistent Perceptual Postural Dizziness (PPPD): This is not vertigo, but it may evolve after having vertigo, persistent disequilibrium - the “chronic fatigue syndrome” of the brain/inner ear axis. More information: https://neurosymptoms.org/en/symptoms/fnd-symptoms/functional-dizziness-pppd/
• Meniere’s disease/syndrome: vertiginous episodes which last hours, usually with associated unilateral aural fullness / tinnitus / fluctuating hearing loss.

All other causes of isolated vertigo, including central causes such as Transient Ischaemic Attack (TIA), acoustic neuroma, Multiple Sclerosis (MS), are rare or very rare. People with brainstem TIA and MS nearly always present with vertigo and other brainstem / focal symptoms.

The most useful investigation is a Dix-Hallpike manoeuvre to identify BPPV which can be viewed below. Routine blood tests and imaging are rarely helpful.

Most people with vertigo do not need secondary care assessment. If you suspect the lesion is in the vestibular apparatus, ENT is the best route. Central brain causes of vertigo other than migraine are rare.

This pathway applies to patients aged 16 years or older, who are resident in the NHS Ayrshire and Arran area.

Patients should be referred to the NHS Ayrshire and Arran visiting neurology service using the SCI Gateway referral template, selecting “Neurology”

If the referring clinician has a particular concern about a patient, they may wish to discuss the patient with the on-call neurology service available through the QEUH switchboard in Glasgow (0141 201 1100) on a 24/7 basis. Please note this is a very busy telephone service, and the caller may have to wait a considerable length of time to be answered. We hence suggest contacting this on-call service only if there is significant concern regarding a sub-acute presentation.

In urgent clinical circumstances where there is risk to a patient in the community, please liaise with your local receiving service.

NHS Inform: Vertigo https://www.nhsinform.scot/illnesses-and-conditions/ears-nose-and-throat/vertigo