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Epidemic vertigo — Clinical Guidelines

Overview

Epidemic vertigo refers to a surge in vertigo cases often observed during specific outbreaks or pandemics, impacting emergency departments significantly. The condition can stem from various causes, including benign peripheral vestibulopathies and, less commonly, central nervous system disorders 18 27.

Diagnosis

Clinical History and Physical Exam: Essential for initial assessment, including the HINTS (head impulse, nystagmus, test of skew) exam to differentiate central from peripheral causes 1 5.

Neuroimaging: Generally not indicated unless suspicion of central pathology persists despite normal neurologic exam 3.

Cervical Spine Imaging: Considered in cases where neck pathology is suspected 9.

Caloric Testing and Bedside Tests: Useful for further evaluation, particularly the triple test (spontaneous nystagmus, head-shaking nystagmus, head impulse test) 17.

Teleconsultation: Valuable during pandemics to assess vertigo without in-person visits 8.

Management

First-Line Treatments:

- Benign Paroxysmal Positional Vertigo (BPPV): Canalith repositioning maneuvers (e.g., Epley maneuver) 19. - Acute Peripheral Vertigo: Intramuscular droperidol or dimenhydrinate can be considered; droperidol may offer efficacy advantages 25.

Adjunctive Treatments:

- Physiotherapy: Enhances central compensation in cases of vestibular loss 35. - Psychological Support: Screening for and managing depression and anxiety, especially in chronic cases 24.

Special Populations

Pediatrics: Vertigo in children often categorized into cochlear diseases, isolated vertigo, and CNS-related causes; specialized otoneurologic evaluation required 21 31.

Elderly: Increased risk of complications and atypical presentations; thorough evaluation including central causes is crucial 18.

Pregnancy: Specific considerations for vertigo may include hormonal changes and increased risk of BPPV; conservative management often preferred 27.

Key Recommendations

Utilize the HINTS exam to differentiate central from peripheral vertigo in emergency settings (Evidence: Moderate 1 5).

Reserve neuroimaging for cases where central nervous system pathology is suspected despite a normal neurologic exam (Evidence: Moderate 3).

Implement teleconsultation protocols during pandemics to maintain patient care while minimizing exposure (Evidence: Expert opinion 8).

Employ canalith repositioning maneuvers as first-line treatment for BPPV (Evidence: Moderate 19).

Screen for depression and anxiety in patients with chronic vertigo to address psychological comorbidities (Evidence: Moderate 24).

References

1 McLean M, Stowens J, Barnicle R, Mafi N, Shah K. Leadership Perceptions, Educational Struggles and Barriers, and Effective Modalities for Teaching Vertigo and the HINTS Exam: A National Survey of Emergency Medicine Residency Program Directors. The western journal of emergency medicine 2025. link 2 Esmail M, Chatterjee P, Parikh K, Quaye MA, Spiegel P. Enhancing integrated epidemic response mechanisms in humanitarian emergencies: a scoping review and qualitative study. BMJ open 2025. link 3 Buyurgan CS, Eray O, Yigit O, Yaprak N, Unal A, Senol U. Diagnostic Contribution of Magnetic Resonance Imaging and Computerized Tomography in Patients with Unidentified Vertigo and Normal Neurologic Examination in Emergency Medicine. Nigerian journal of clinical practice 2023. link 4 Hu B, Jiang G, Yao X, Chen W, Yue T, Zhao Q et al.. Allocation of emergency medical resources for epidemic diseases considering the heterogeneity of epidemic areas. Frontiers in public health 2023. link 5 Byworth M, Johns P, Pardhan A, Srivastava K, Sharma M. Factors influencing HINTS exam usage by Canadian Emergency Medicine Physicians. CJEM 2022. link 6 Silva M, Tallman P, Stolow J, Yavinsky R, Fleckman J, Hoffmann K. Learning From the Past: The Role of Social and Behavior Change Programming in Public Health Emergencies. Global health, science and practice 2022. link 7 Ueda K, Ota I, Yamanaka T, Kitahara T. The Impact of the COVID-19 Pandemic on Follow-Ups for Vertigo/Dizziness Outpatients. Ear, nose, & throat journal 2021. link 8 Bertholon P, Thai-Van H, Bouccara D, Esteve-Fraysse MJ, Wiener-Vacher SR, Ionescu E. Guidelines of the French Society of Otorhinolaryngology (SFORL) for teleconsultation in patients with vertigo during the COVID-19 pandemic. European annals of otorhinolaryngology, head and neck diseases 2021. link 9 Bécares-Martínez C, López-Llames A, Martín-Pagán A, Cores-Prieto AE, Arroyo-Domingo M, Marco-Algarra J et al.. Cervical spine radiographs in patients with vertigo and dizziness. La Radiologia medica 2020. link 10 Copper FA, Mayigane LN, Pei Y, Charles D, Nguyen TN, Vente C et al.. Simulation exercises and after action reviews - analysis of outputs during 2016-2019 to strengthen global health emergency preparedness and response. Globalization and health 2020. link 11 Omron R. Peripheral Vertigo. Emergency medicine clinics of North America 2019. link 12 Ohlendorf D, Doerry C, Fisch V, Schamberger S, Erbe C, Wanke EM et al.. Standard reference values of the postural control in healthy young female adults in Germany: an observational study. BMJ open 2019. link 13 Peñas JA, de Los Reyes VC, Sucaldito MNL, Ballera JED, Hizon HL, Magpantay RL et al.. Epidemic hysteria following the National School Deworming Day, Zamboanga Peninsula, Philippines, 2015. Western Pacific surveillance and response journal : WPSAR 2018. link 14 Jia J, Jin Z, Chang L, Fu X. Structural calculations and propagation modeling of growing networks based on continuous degree. Mathematical biosciences and engineering : MBE 2017. link 15 Vanni S, Nazerian P, Casati C, Moroni F, Risso M, Ottaviani M et al.. Can emergency physicians accurately and reliably assess acute vertigo in the emergency department?. Emergency medicine Australasia : EMA 2015. link 16 Lüscher M, Theilgaard S, Edholm B. Prevalence and characteristics of diagnostic groups amongst 1034 patients seen in ENT practices for dizziness. The Journal of laryngology and otology 2014. link 17 Rohrmeier C, Richter O, Schneider M, Wirsching K, Fiedler I, Haubner F et al.. Triple test as predictive screen for unilateral weakness on caloric testing in routine practice. Otology & neurotology : official publication of the American Otological Society, American Neurotology Society [and] European Academy of Otology and Neurotology 2013. link 18 Kerber KA. Vertigo presentations in the emergency department. Seminars in neurology 2009. link 19 Beyea JA, Wong E, Bromwich M, Weston WW, Fung K. Evaluation of a particle repositioning maneuver Web-based teaching module. The Laryngoscope 2008. link 20 Siermala M, Juhola M. Techniques for biased data distributions and variable classification with neural networks applied to otoneurological data. Computer methods and programs in biomedicine 2006. link 21 Riina N, Ilmari P, Kentala E. Vertigo and imbalance in children: a retrospective study in a Helsinki University otorhinolaryngology clinic. Archives of otolaryngology--head & neck surgery 2005. link 22 Hanprasertpong C, Koizumi Y, Aoyagi M, Kimura M, Yagi T. A head-mounted visual stimulator for neurotological examination. Auris, nasus, larynx 2004. link 23 Guilemany JM, Martínez P, Prades E, Sañudo I, De España R, Cuchi A. Clinical and epidemiological study of vertigo at an outpatient clinic. Acta oto-laryngologica 2004. link 24 Grunfeld EA, Gresty MA, Bronstein AM, Jahanshahi M. Screening for depression among neuro-otology patients with and without identifiable vestibular lesions. International journal of audiology 2003. link 25 Irving C, Richman P, Kaiafas C, Eskin B, Allegra J. Intramuscular droperidol versus intramuscular dimenhydrinate for the treatment of acute peripheral vertigo in the emergency department: a randomized clinical trial. Academic emergency medicine : official journal of the Society for Academic Emergency Medicine 2002. link 26 Viikki K, Kentala E, Juhola M, Pyykkö I, Honkavaara P. Generating decision trees from otoneurological data with a variable grouping method. Journal of medical systems 2002. link 27 Blakley BW, Goebel J. The meaning of the word "vertigo". Otolaryngology--head and neck surgery : official journal of American Academy of Otolaryngology-Head and Neck Surgery 2001. link 28 Baloh RW. Charles Skinner Hallpike and the beginnings of neurotology. Neurology 2000. link 29 Prakash J. Acute renal failure in epidemic dropsy. Renal failure 1999. link 30 Kentala E, Auramo Y, Juhola M, Pyykkö I. Comparison between diagnoses of human experts and a neurotologic expert system. The Annals of otology, rhinology, and laryngology 1998. link 31 D'Agostino R, Tarantino V, Melagrana A, Taborelli G. Otoneurologic evaluation of child vertigo. International journal of pediatric otorhinolaryngology 1997. link00032-3) 32 Kentala E, Pyykkö I, Auramo Y, Juhola M. Otoneurological expert system. The Annals of otology, rhinology, and laryngology 1996. link 33 Cappello M, di Blasi U, di Piazza L, Ducato G, Ferrara A, Franco S et al.. Dizziness and vertigo in a department of emergency medicine. European journal of emergency medicine : official journal of the European Society for Emergency Medicine 1995. link 34 Viaud DP. Large deviations for discrete-time epidemic models. Mathematical biosciences 1993. link90023-4) 35 Odkvist I, Odkvist LM. Physiotherapy in vertigo. Acta oto-laryngologica. Supplementum 1988. link

Epidemic vertigo