Vertigo

Extract

[...] System(s) Affected: Nervous Synonym(s): Dizziness; Acute vestibular neuronitis; Labyrinthitis; Benign paroxysmal positional vertigo (BPPV) GENERAL PREVENTION Precautions to avoid injuries from falls that may occur secondary to imbalance If due to motion sickness, pretreatment with anticholinergics such as scopolamine EPIDEMIOLOGY Women are more likely to experience central causes, particularly vertiginous migraine. Patients who are elderly and have risk factors for cerebrovascular disease (CVD) are more likely to experience central causes. Incidence Accounts for 54% of cases of dizziness reported in primary care: of these patients are diagnosed with peripheral causes, such as BPPV. [...]

[...] Treatments depend on cause - BPPV: Epley maneuver or modified Epley maneuver - Vestibular neuronitis and labyrinthitis à Vestibular suppressant medications Vestibular rehabilitation exercises - Meniere disease: Low-salt diet Diuretics such as hydrochlorothiazide - Vascular ischemia Prevention of future events through blood pressure reduction, lipid lowering, smoking cessation, antiplatelet therapy, and anticoagulation if necessary - Vertiginous migraines Dietary and lifestyle modifications, vestibular rehabilitation exercises, prophylactic and migraine abortive medications - Drug-induced vertigo Discontinue causative agent - Psychological SSRIs Diet Restricted salt intake for Meniere disease Dietary modifications for vertiginous migraine SPECIAL THERAPY Epley maneuver or modified Epley maneuver for BPPV to displace calcium deposits in the semicircular canals Improves symptoms and converts patient from positive to negative Dix-Hallpike maneuver Contraindications: Carotid stenosis, unstable cardiac disease, severe neck disease Physical Therapy Vestibular rehabilitation exercises Ball toss Lying-to-standing Target-change Thumb-tracking Tightrope Walking turns MEDICATION (DRUGS) First Line Meclizine (Antivert): 12.5 -50 mg PO q4-8h Dimenhydrinate (Dramamine): 25-100 mg PO, IM, or IV q4-8h - Precautions: Concomitant use of CNS depressants, prostatic hyperplasia, glaucoma - Adverse effects: Sedation, xerostomia - Interactions: CNS depressants Prochlorperazine (Compazine): 5-10 mg PO or IM q6-8h; 25 mg rectally q12h; 5-10 mg by slow IV over 2 minutes - Contraindications: Blood dyscrasias, age years, severe hypotension - Precautions: Children with acute illness; glaucoma, history of breast cancer, impaired cardiovascular function, pregnancy, prostatic hyperplasia - Adverse effects: Sedation, xerostomia, hypotension, extrapyramidal effects - Interactions: Phenothiazines, tricyclic antidepressants Metoclopramide (Reglan): 5-10 mg PO q6h, 5-10 mg slow IV q6h - Contraindications: Concomitant use of drugs with extrapyramidal effects, seizure disorders - Precautions: History of depression, Parkinson disease, hypertension - Adverse effects: Sedation, fluid retention, constipation - Interactions: Linezolid, cyclosporine, digoxin, levodopa Benzodiazepines - Diazepam (Valium): 2-10 mg PO or IV q4-8h - Lorazepam (Ativan): 0.5 mg PO, IM, or IV q4-8h Contraindications: Glaucoma, age months Precautions: Concomitant use of CNS depressants, hepatic insufficiency, pregnancy Adverse effects: Sedation, respiratory depression, hypotension Interactions: CNS depressants ALERT Geriatric Considerations Use vestibular suppressant medications with caution - Increased risk of falls - Urinary retention Pregnancy Considerations Meclizine and dimenhydrinate are Pregnancy Category B Conclusions Consider referral to otolaryngologist, ENT specialist, or neurologist if patient [...]