The Patient with Vertigo

Vertebral artery dissection

Like VBI, vertebral artery dissection can lead to decreased perfusion in the posterior circulation of the brain and can result in stroke. Mechanisms that can cause this injury include anything that can result in sudden and violent rotation or extension of the neck, such as high-velocity motor vehicle crashes, diving injuries, coughing, sneezing and chiropractic neck adjustments (although the likelihood is low).5 Signs and symptoms of vertebral artery dissection include vertigo, headache and unilateral Horner syndrome.

The Patient History: Delineating Vertigo from Nonvertiginous Dizziness

Obtaining a detailed history of the patient’s complaint is the key to differentiating vertigo from nonvertiginous dizziness. First, ask the patient to describe her symptoms, using words other than “dizzy.” Patients may use the term “dizzy” nonspecifically to describe sensations of weakness, unsteadiness, near-syncope, syncope and vertigo. Descriptions of whirling, spinning or motion while at rest are consistent with vertigo. Oftentimes, patients will describe being dizzy while lying in bed or turning over in their sleep. Specifically ask the patient if dizziness increases upon standing quickly, as this is suggestive of a cardiovascular origin that requires further evaluation.

Peripheral vertigo may cause distressing symptoms, but is seldom life-threatening. Episodes tend to .begin and resolve suddenly and can last from minutes to hours. Symptoms are fairly specific. Complaints such as ear pressure or fullness, tinnitus and hearing loss are common. Changes in position tend to provoke the sensation of vertigo, and lying still tends to relieve it. The patient is often without complaint between spells.

Disorders causing central vertigo may produce less distressing and more variable symptoms that have a slower onset than those due to peripheral vertigo. Central vertigo is often less severe than peripheral, and is often accompanied by other neurological complaints. With the exception of VBI, sudden head movements will typically not provoke the sensation of vertigo. Table 3 contains a summary of the differences observed between peripheral and central vertigo.

Treatment

The treatment of vertigo is mostly supportive. As patients with peripheral vertigo may experience a worsening of symptoms with head movement, an effort should be made to place the patient in a position of comfort that will minimize such movements. Patients with severe nausea and vomiting may benefit from intravenous fluid and antiemetic medications such as ondansetron (Zofran) or prochlorperazine (Compazine). Diazepam, midazolam or other benzodiazepines may be helpful as a vestibular suppressant for patients with severe vertigo. If you suspect the vertigo has a cardiovascular origin, always err on the side of caution and perform a 12-lead ECG and orthostatic testing.

Assume that patients with signs and symptoms consistent with central vertigo are having a stroke until proven otherwise in the ED, and treat per established protocol. Administer oxygen, do cardiac monitoring, obtain peripheral IV access and consider transport to a stroke center.

Case Conclusion

“I’m not sure you are having a heart attack, but I want to ask you some more questions,” Lafe tells Linda. “Can you describe the sensation you are feeling without using the word ‘dizzy’?” Linda thinks about it and says, “I feel like the room is spinning, even though I’m lying still. It is getting a little better, though, as I’m lying here.” Lafe then asks about the onset of dizziness and nausea. “I awoke feeling fine, but the spinning started as soon as I rolled over to get out of bed and stood up. Then I felt like I was going to throw up. This went on for about an hour before I called you. I start to feel OK when I’m lying down, but it gets real bad when I try to get out of bed.”