Vertigo: Diagnosis and Management

EPIDEMIOLOGY
The incidence of dizziness in the general population ranges from 20% to 30%, and with every five-year increase in age, there is a 10% increase in incidence of dizziness.¹⁰ Approximately 7.5 million patients are seen in ambulatory care annually with the chief complaint of dizziness.¹⁰ Further, with the increasing age of the US population, the incidence and prev­alence of dizziness, and hence, of BPPV, will likely increase over the next 20 years.

BPPV is the most common vestibular disorder across the lifespan and most commonly presents between the fifth and seventh decade of life.⁴ The average age of onset of BPPV is 51 years,³ and it is rarely seen in those 35 and younger without a history of head trauma. The prevalence has been reported to range from 10.7 to 64 per 100,000 population, with a lifetime prevalence of 2.4%.^4,11 It is estimated that 9% of elderly patients have unrecognized BPPV and experience greater risk for falls, depression, and interference with activities of daily living as a result.¹² This, in turn, can lead to increased caregiver burden, decreased family productivity with resultant costs to society, and increased risk for nursing home placement. When not properly diagnosed and treated, BPPV can lead to significant morbidity, psychosocial problems, and increased medical costs.¹³

One of the main causes of BPPV is head trauma. Other predisposing factors include inactivity, major surgery, acute alcoholism, and CNS disease. BPPV is idiopathic in approximately 50% to 70% of cases.⁶ Spontaneous remission of BPPV can occur within days to months, or it can resolve after treatment and then recur.⁷ The recurrence rate of BPPV has been shown to be between 50% to 56% in some studies.¹¹

Neuhauser et al¹³ evaluated the burden of dizziness within the general population in Germany, screening a cross-sectional sample of 4,869 participants for moderate or severe dizziness. The researchers estimated that 1.8% of adults seek medical care annually for new symptoms of moderate or severe dizziness or vertigo, and that vestibular vertigo accounts for approximately one third of cases of dizziness and vertigo seen in the medical setting. They commented that the latter finding is in line with other studies that have estimated that more than half of cases of dizziness in the medical setting (primary care, specialty care, and ED) are diagnosed as vestibular vertigo. The researchers also found that medical consultations and hospital visits were more frequent for vestibular vertigo than for nonvestibular dizziness. They concluded that more consideration should be given in primary care to common vestibular disorders, particularly BPPV, for which inexpensive and effective treatment with positioning maneuvers can be performed in the primary care setting.¹³

SUBOPTIMAL MANAGEMENT OF VERTIGO AND BPPV
Although vertigo can be debilitating and significantly reduce patients’ quality of life,¹³ 40% to 80% of cases remain unexplained and therefore go untreated.¹⁴ BPPV not only affects patients physically but can also have serious effects on their emotional well-being.¹⁵ Anxiety has been found to be associated with BPPV in some cases. It is estimated that 86% of patients with BPPV symptoms experience problems with activities of daily living and experience work absences.¹¹

According to clinical practice guidelines developed by the American Academy of Otolaryngology–Head and Neck Surgery (AAOHNS),health care costs associated with the diagnosis of BPPV alone approach $2 billion per year, and it costs approximately $2,000 per patient to arrive at a diagnosis of BPPV.⁴ A recent retrospective study examined 1,681 patients who presented to the ED with complaints of vertigo and dizziness over a three-year period.⁹ Nearly half the patients received a CT scan of the brain and head, resulting in a total cost of $988,200. However, fewer than 1% of the CTs revealed an underlying condition that required intervention. The researchers concluded that, for patients presenting with isolated dizziness, lightheadedness, or vertigo without other symptoms, the likelihood of finding an acute life-threatening abnormality on CT is low, and therefore CT is not helpful.

Newman-Toker et al⁸ studied 9,472 dizzy patients who visited the ED over a 13-year period; of the 7.4% who were diagnosed with a vestibular disorder, 84% had BPPV or acute peripheral vestibulopathy.⁸ Patients diagnosed with BPPV were more likely to undergo diagnostic imaging with CT and more likely to receive a prescription for the vestibular suppressant meclizine than nondizzy patients. The researchers concluded that these patients were not managed optimally, citing overuse of diagnostic imaging and prescription meclizine, which is not indicated for treating BPPV.⁸

The use of unnecessary diagnostic testing for the work-up of vertigo has been well documented in the literature. However, the trend of diagnostic imaging for vertigo and dizziness has continued, imposing an economic burden on the health care system. The reason for this may be twofold. First, primary care and ED providers may not feel confident in their ability to recognize and diagnose BPPV. Second, an underlying component may be the clinician’s perceived need to practice defensive medicine.

A report published by the Department of Health and Human Services included a physician survey regarding litigation.¹⁶ Of those surveyed, 79% responded that they had ordered more tests than they felt were needed, due to the fear of being sued. By extrapolation, it is reasonable to assume that similar practices and concerns may apply to nurse practitioners, of whom 70% to 80% work in primary care,¹⁷ as well as physician assistants in primary care.

Although medications are used frequently for treating dizziness, this practice is not supported by evidence-based criteria.⁷ Overuse of vestibular suppressants for treatment of BPPV has been identified in the literature in both primary care settings and the ED; in particular, use of meclizine for treatment of dizziness and vertigo needs to be reconsidered.^4,8

On the next page: Pathophysiology and patient presentation >>