Acute positional vertigo in the emergency department—peripheral vs. central positional nystagmus

Abstract

IntroductionBenign paroxysmal positional vertigo (BPPV) is the most common cause of positional vertigo. However, positional vertigo can also be due to diseases affecting the central vestibular pathways, such as vestibular migraine. Accurate and timely diagnosis enables effective triage and management.ObjectivesTo evaluate diagnoses made by emergency clinicians compared to acute vertigo specialists, in patients presenting to an emergency department (ED) with positional vertigo.MethodsFollowing routine ED care, patients with a primary complaint of dizziness, vertigo, light-headedness or unsteadiness, underwent detailed neuro-otological assessment by acute vertigo specialists. Demographics and final diagnoses were recorded and analyzed.ResultsOf 71 consented patients (21−91 years; mean 56 years, ±16.7 years, 40 females), ED identified 13 with a peripheral cause of positional vertigo (mean 48.85 years, ±16.19, 8 females). Central positional nystagmus was not noted in any of the patients with positional vertigo seen by the ED clinicians. Acute vertigo specialists diagnosed nine patients with BPPV (age range 50-88 years, mean 66 years, ±12.22, 5 females), and six with central positional nystagmus (age range 23−59 years, mean 41.67 years, ±15.78, 6 females).ConclusionPositional vertigo should be assessed with positional maneuvers such as Dix-Hallpike and Roll tests in the ED to identify peripheral and central nystagmus features. Central causes are more common in younger females, with the presence of vomiting, and/or a background of motion sensitivity.

Residual dizziness after BPPV management: exploring pathophysiology and treatment beyond canalith repositioning maneuvers

“…Up to 20% of cases of positional vertigo may be due to central pathology (29), caused by disease affecting the central nervous system, such as multiple sclerosis, cerebellar disease, and cerebellar stroke, with vestibular migraine being the most common central cause (30). Suspicion of central positional vertigo may be raised with an absence of latency or fatigability of nystagmus, a lack of marked vertigo, pure upbeat or downbeat nystagmus, or as a lack of responsiveness to CRM (31).…”