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Ear, nose and throat Neurological

Vertigo

Last revised in December 2022

Vertigo is a symptom, not a diagnosis. It refers to a false sensation of movement (spinning or rotation) of the person or their surroundings

Vertigo: Summary

  • Vertigo is a symptom, not a diagnosis. It refers to a false sensation of movement (spinning or rotation) of the person or their surroundings in the absence of any actual physical movement.
  • Vertigo can adversely affect quality of life, independence, and activities such as driving and employment. Vertigo also increases the likelihood of falls and anxiety.
  • Most balance problems that present in primary care are not true rotatory vertigo.
  • It is important to differentiate peripheral from central vertigo.
    • Peripheral vertigo is more common and is usually caused by a problem with the inner ear affecting the labyrinth or vestibular nerve (for example benign paroxysmal positional vertigo, vestibular neuronitis, labyrinthitis, and Meniere’s disease).
    • Central vertigo is uncommon and is usually caused by pathology in the brainstem and cerebellum (for example stroke, transient ischaemic attack, cerebellar tumour, and multiple sclerosis).
  • Examination should include looking for facial asymmetry, examination of the ear, testing of cranial nerves and cerebellar function, examination of the eyes, and checking for signs of peripheral neuropathy and abnormal gait.
  • Specific tests such as Romberg’s test, the Dix-Hallpike manoeuvre, the head impulse test, Unterberger’s test and the alternate cover test can give useful information on the origin of vertigo.
  • If peripheral vertigo is suspected, the history and examination findings can be used to differentiate between conditions, in particular benign paroxysmal positional vertigo (BPPV), vestibular neuronitis and labyrinthitis and Meniere's disease.
  • A central cause of vertigo should be suspected when the signs and symptoms do not match the features of any of the peripheral causes with reasonable accuracy.
    • Features increasing suspicion of a central cause of vertigo include prolonged, severe vertigo; new-onset headache or recent trauma; focal neurological signs and symptoms; central-type nystagmus; an abnormal response to the Dix-Hallpike manoeuvre; and an inability to stand up or walk even with the eyes open.
  • Management of vertigo will depend on the suspected underlying cause and associated clinical findings. It may include admission to hospital if there are worrying features, or referral to a specialist for confirmation of the diagnosis.

Have I got the right topic?

From age 18 years onwards.

This CKS topic covers the diagnosis of vertigo, how to determine the underlying cause of vertigo, and the management and referral in primary care of peripheral vertigo (including that of unknown cause) and central causes of vertigo.

This CKS topic does not cover the diagnosis, management, and referral of people with other forms of dizziness (for example light-headedness). The management of migrainous vertigo and less common causes of vertigo (for example acoustic neuroma, perilymph fistula) is also not covered.

There are separate CKS topics on Benign paroxysmal positional vertigo, Brain and central nervous system cancers - recognition and referral, Falls - risk assessment, Head injury, Meniere's disease, Migraine, Stroke and TIA, Tinnitus, and Vestibular neuronitis.

The target audience for this CKS topic is healthcare professionals working within the NHS in the UK, and providing first contact or primary healthcare.

How up-to-date is this topic?

Changes

December 2022 — reviewed. A literature search was conducted in November 2022 to identify evidence-based guidelines, UK policy, systematic reviews, and key RCTs published since the last revision of the topic. No major changes have been made to recommendations. 

Previous changes

November 2020 — minor update. Restless legs syndrome added as an adverse effect or promethazine teoclate in line with the updated manufacturer's SPC. 

December 2017 — reviewed. A literature search was conducted in August 2017 to identify evidence-based guidelines, UK policy, systematic reviews, and key RCTs published since the last revision of the topic. There have been structural changes to the topic and a new section has been created on prognosis. Detail has been added on differentiating features of central and peripheral causes of vertigo and the alternate cover test is now included as a specific test to consider when examining a person with vertigo.

July 2013 — minor update. Links to the DVLA website have been updated.

January 2011 — minor update. Text amended. The management of benign paroxysmal positional vertigo is now covered in the CKS topic on Benign paroxysmal positional vertigo.

January to April 2010 — this is a new CKS topic. The evidence base has been reviewed in detail, and recommendations are clearly justified and transparently linked to the supporting evidence.

Update

New evidence

Evidence-based guidelines

No new evidence-based guidelines since 1 December 2022.

HTAs (Health Technology Assessments)

No new HTAs since 1 December 2022.

Economic appraisals

No new economic appraisals relevant to England since 1 December 2022.

Systematic reviews and meta-analyses

No new systematic reviews published since 1 December 2022.

Primary evidence

No new observational studies published since 1 December 2022.

New policies

No new national policies or guidelines since 1 December 2022.

New safety alerts

No new safety alerts since 1 December 2022.

Changes in product availability

No changes in product availability since 1 December 2022.

Goals and outcome measures

Goals

To support primary healthcare professionals to:

  • Determine the underlying cause of vertigo, where possible.
  • Identify people with vertigo who require urgent referral or admission to hospital.
  • Appropriately refer people with vertigo to a specialist.
  • Offer symptomatic treatment, where appropriate.

Outcome measures

No outcome measures were found during the review of this topic.

Audit criteria

No audit criteria were found during the review of this topic.

QOF indicators

No QOF indicators were found during the review of this topic.

QIPP - options for local implementation

No QIPP criteria were found during the review of this topic.

NICE quality standards

  • No NICE quality standards were found during the review of this topic.

Background information

What is it?

  • Vertigo is a symptom, not a diagnosis. It refers to a false sensation of movement (spinning or rotation) of the person or their surroundings in the absence of any actual physical movement [Rivlin, 2022].
  • In contrast, dizziness is a perception of disturbed or impaired spatial orientation, but there is no false sense of motion. 'Dizziness' is commonly used as a non-specific term to describe a number of symptoms, including [Agarwal, 2022]:
    • Vertigo.
    • Presyncope — a sensation of being about to lose consciousness, usually caused by a decrease in global cerebral blood flow.
    • Disequilibrium/unsteadiness — a feeling of being unstable while sitting, standing, or walking.
    • Light-headedness — not clearly defined.

What causes it?

  • The cause of vertigo may be: 
    • Peripheral— usually caused by a problem with the inner ear affecting the labyrinth or vestibular nerve.  Peripheral vertigo is the most common type.
    • Central — caused by pathology in the brain, for example, brainstem or cerebellum. Central causes are uncommon. 
  • Causes of peripheral vertigo include [Omron, 2019; BMJ Best Practice, 2021; Agarwal, 2022]: 
    • Benign paroxysmal positional vertigo. For more information, see the CKS topic on Benign paroxysmal positional vertigo.
    • Vestibular neuronitis and labyrinthitis. For more information, see the CKS topic on Vestibular neuronitis.
    • Meniere's disease. For more information, see the CKS topic on Meniere's disease.
    • Perilymphatic fistula, labyrinthine concussion, vestibular ototoxicity, (for example drug-related damage), semicircular canal dehiscence syndrome, and syphilis (less common causes).
  • Causes of central vertigo include [BMJ Best Practice, 2022a; Rivlin, 2022]:
    • Migraine — the most common cause of central recurrent attacks of vertigo. Features of vestibular migraine include ataxia, visual disorders, occipital pressure, and nausea and vomiting. It can be difficult to distinguish from early Meniere's disease. For more information, see the CKS topic on Migraine.
    • Stroke and transient ischaemic attack, cerebellar tumour, acoustic neuroma, and multiple sclerosis (less common causes). For more information, see the CKS topics on Brain and central nervous system cancers - recognition and referral, Multiple sclerosis, and Stroke and TIA.
  • Vertigo may present as part of the acute vestibular syndrome, defined as acute onset dizziness and/or vertigo [Rivlin, 2022]; intolerance of head movement; continuous dizziness of 24 hours to several weeks' duration; spontaneous or gaze-evoked nystagmus; unsteadiness of gait; nausea and/or vomiting [Venhovens, 2016]. This can be caused by peripheral conditions (for example vestibular neuronitis or labyrinthitis) or central pathology (for example ischaemic or haemorrhagic stroke of the cerebellum or brainstem, or multiple sclerosis).

How common is it?

  • Most balance problems that present in primary care are not true rotatory vertigo.
    • A 2018 systematic review showed that, of people presenting with symptoms of dizziness in the community, around 44% had vertigo of peripheral origin [Bösner, 2018].
    • Prevalence estimates varied widely according to heterogeneity of 'dizziness' as a presenting symptom. Dizziness has an estimated prevalence between 17-30%, and true vertigo 3-10% [BMJ Best Practice, 2021].
    • A systematic review of 20 studies of the epidemiology of balance symptoms and disorders in the community estimated the lifetime prevalence of vertigo to be 3–10% [Murdin and Schilder, 2015].
    • A German study found that, in a year, around 1% of adults attend for medical assessment with new onset vertigo [Neuhauser, 2016].
  • The most common causes of vertigo symptoms in primary care are benign paroxysmal positional vertigo (BPPV), Meniere's disease, and vestibular neuronitis [BMJ Best Practice, 2022a]:
    • In a 2021 study looking at vertigo in older adults, 48% of cases were due to peripheral vestibular disorders (20% of cases were due to BPPV) [Casani, 2021]. The effect of comorbidities and pharmacotherapy were also important factors.

What are the complications?

  • Vertigo can adversely affect quality of life and independence. The symptoms can be disabling, affecting daily functioning and activities such as driving and employment.
  • Vertigo increases the risk of falls and the likelihood of anxiety, panic, or social phobia.

[BMJ Best Practice, 2022a; DVLA, 2022]

What is the prognosis?

Diagnosis of vertigo

How do I know my patient has vertigo?

  • People with vertigo usually describe rotatory or spinning symptoms. To determine that the person has vertigo rather than non-rotatory dizziness (for example presyncope, disequilibrium, or light-headedness) ask in detail about their symptoms, in particular, the timing and the triggers [Rivlin, 2022]. For example:
    • 'Light-headedness' triggered by postural change (and without head positional change) is more likely to be orthostatic hypotension.
    • Recurring symptoms triggered by head movement (such as turning over in bed or reaching for an object from the floor or a high shelf) are more likely to be benign paroxysmal positional vertigo.
  • If the person has nystagmus it is likely that their dizziness is vertigo. 

Basis for recommendation

Experts emphasize the importance of identifying vertigo as opposed to other non-rotational types of dizziness to enable an appropriate diagnosis to be made [Agarwal, 2022; Rivlin, 2022; Stanton, 2022]. A finding of nystagmus is suggestive of vertigo [Hogue, 2015; BMJ Best Practice, 2021; BMJ Best Practice, 2022b].  

  • The questions about timing and triggers are taken from the article A practical approach to vertigo: a synthesis of the emerging evidence [Rivlin, 2022].

How should I assess a person with vertigo?

  • If a person presents with vertigo, ask about:
    • The vertigo.
      • Timing of symptoms — duration, onset, and frequency.
      • Aggravating factors (such as movement of the head).
      • Severity and effect on daily activities (such as walking).
    • Associated symptoms.
      • Nausea and vomiting.
      • Otological — such as hearing loss, ear discharge, a feeling of fullness in the ear, or tinnitus.
      • Neurological — such as headache, diplopia, visual disturbance, dysarthria or dysphagia, paraesthesia, muscle weakness, ataxia, or migraine aura.
    • Relevant medical history.
      • Recent upper respiratory tract infection or ear infection — suggestive of vestibular neuronitis or labyrinthitis.
      • Migraine — increases the likelihood of the vertigo being migrainous.
      • Head trauma or recent vestibular neuronitis — may suggest benign paroxysmal positional vertigo (but trauma can also indicate a central cause).
      • Direct trauma to the ear or head trauma — consider perilymphatic fistula (but trauma can also indicate a central cause).
      • Anxiety or depression — may manifest as dizziness or vertigo, especially if the person hyperventilates.
      • Cardiovascular risk factors (such as previous angina or myocardial infarction, diabetes, hypertension, smoking, and atrial fibrillation) — increase the likelihood of stroke as the cause of vertigo.
      • Drugs (such as aminoglycosides, furosemide, antidepressants, and antipsychotics) — may cause vertigo.
      • Acute intoxication with alcohol — may cause vertigo.
      • Family history of migraine or Meniere's disease — may increase the likelihood of these conditions.
  • When examining a person with vertigo:
    • Examine the ear — look for discharge, vesicular eruptions (indicating herpes zoster infection) , and signs of cholesteatoma (for example a retraction pocket).
    • Perform a neurological examination:
      • Look at the person's face for signs of asymmetry suggestive of peripheral facial nerve involvement or a cerebrovascular event.
      • Test cranial nerves and cerebellar function (for example heel to toe walking).
      • Examine the eyes for nystagmus — note its direction and whether it is affected by changing the direction of gaze or fixing the eyes on an object.
      • Perform fundoscopy.
      • Check for signs of peripheral neuropathy.
      • Examine the person's gait, coordination, and their ability to stand unaided. If symptoms are too severe to allow walking, ask the person to sit upright without holding on to anything.
    • Perform a cardiovascular examination (blood pressure, heart rate and rhythm, and carotid examination for bruits).
    • Consider using specific clinical tests:
      • Romberg's test — to identify instability of either peripheral or central cause (although it is not a sensitive test for differentiating between them). 
      • Dix-Hallpike manoeuvre — (if the person has positional vertigo affected by moving the head) to help make a diagnosis of benign paroxysmal positional vertigo.
      • Head impulse test — to detect unilateral hypofunction of the peripheral vestibular system, and to help differentiate between cerebellar infarction and vestibular neuronitis.
      • Unterberger's test — to identify dysfunction of one of the labyrinths.
      • Alternate cover test — an abnormal result suggests an increased likelihood of stroke in a person with acute vestibular syndrome.

Romberg's test

  • Ask the person to stand up straight with their feet together (or at a distance at which they are steady), and then shut their eyes.
  • Stay close by to prevent the person from falling if they become unsteady.
  • If the person cannot maintain their balance when their eyes are closed the test is positive.
    • A positive test suggests a problem with proprioception or vestibular function. It is therefore useful in identifying instability associated with vertigo, but not in distinguishing between peripheral and central causes of vertigo.

Dix-Hallpike manoeuvre

  • Be cautious when considering the Dix-Hallpike manoeuvre if the person has a neck or back problem, or cardiovascular problems such as carotid sinus syncope, as it involves turning the head and extending the neck. If in doubt about the safety of the manoeuvre, seek specialist advice or refer the person to a medically qualified balance specialist (such as an ear, nose, and throat specialist or an audiovestibular physician).
  • To carry out the manoeuvre: 
    • Advise the person that they may experience transient vertigo during the procedure.
    • Ask the person to keep their eyes open throughout the manoeuvre and to look straight ahead.
    • Ask the person to sit upright on the couch with their head turned 45 degrees to one side.
    • From this position, lie the person down rapidly (over 2 seconds), supporting their head and neck, until their head is extended 20–30 degrees over the end of the couch with the chin pointing slightly upwards and the test ear downwards. Support the head to maintain this position for at least 30 seconds. 
    • Observe their eyes closely for up to 30 seconds for the development of nystagmus. If nystagmus is present, maintain the position for its duration (maximum 2 minutes if persistent) and note its duration, type, direction, and latency. 
    • Record the duration, severity, and latency of any vertigo.
    • Support the head in position, and slowly sit the person up.
    • Repeat with the head rotated 45 degrees to the other side.
  • On repeat testing, the nystagmus becomes less obvious (fatigues). However, it is not recommended to repeat the Dix-Hallpike manoeuvre to confirm fatiguability because of the unpleasant vertigo symptoms it induces.
  • A video of the Dix-Hallpike manoeuvre may help to illustrate the procedure.
  • Diagnose posterior semi-circular canal BPPV if the Dix-Hallpike manoeuvre provokes vertigo and torsional (rotatory) upbeating nystagmus (the upper pole of the eye beats towards the dependent ear with the vertical component towards the forehead when looking straight ahead). Left ear BPPV has a clockwise torsional nystagmus, right ear BPPV nystagmus rotates anti-clockwise.
    • There is a latent period (usually of 5 to 20 seconds) between completing the manoeuvre and onset of vertigo and nystagmus. 
    • The vertigo and nystagmus increase in intensity, then decline, but should resolve within 1 minute of nystagmus onset.
    • Less intense nystagmus in the opposite direction may occur for a short time on sitting upright.

Head impulse test

  • Use caution if the person has neck pathology (for example cervical spine disease), as the head impulse test involves rapid repositioning of the head. Always start by asking the person to rotate their neck themselves to assess for any limitation of neck movement. If in doubt about the safety of the manoeuvre, seek specialist advice or refer the person to a balance specialist.
  • To carry out the head impulse test:
    • Advise the person to sit upright and to fix their gaze on the examiner.
    • Then rapidly turn the head 10–20 degrees to one side and watch the person's eyes. In a normal response (indicating a normal peripheral vestibular system), the eyes stay fixed on the examiner. If the eyes are dragged off target by the head turn, a corrective abnormal movement (saccade) occurs as the eyes move back to fix on the examiner.
    • Repeat several times to the same or opposite side, randomly and unpredictably, until satisfied as to the consistent presence or absence of the corrective saccade.
      • A corrective saccade represents a positive test (disrupted vestibulo-ocular reflex) and implies moderate to severe loss of function of the horizontal semi-circular canal on the side to which the test is positive.

Alternate cover test

  • Use the alternate cover test to examine for skew deviation.
    • Ask the person to look at the examiner's nose, then alternately cover their right eye and left eye a number of times.
    • Do this for several cycles, focusing on one eye at a time, watching for vertical correction when the covered eye is uncovered (upward on one side, downward on the other side).
  • No vertical correction indicates a normal response, but in a person with skew deviation there will be vertical correction, which increases suspicion of stroke in a person with acute vestibular syndrome.

Unterberger's test

  • Ask the person to march on the spot with their eyes closed, and observe them for lateral rotation.
  • If there is labyrinthine damage, the person will rotate to the side of the affected labyrinth.

Basis for recommendation

Assessment

  • Experts advise diagnosing a cause for vertigo taking into account the duration of attacks, frequency, associated factors, and non-vestibular symptoms [Brandt, 2017]. A review article on the assessment of balance disorders notes the importance of the history in ascertaining the likely origin of the balance disorder, and advises a thorough examination [BMJ Best Practice, 2021].  
  • Review articles state that the history and examination can differentiate between central and peripheral causes and help to make the diagnosis in the majority of cases [Agarwal, 2022; Rivlin, 2022], with the history alone leading to the diagnosis in around three-quarters of dizzy people [Hogue, 2015]. Other experts report evidence that the physical examination can aid a confident diagnosis of a specific peripheral vestibular disorder or stroke [Edlow, 2016]. 
  • The recommendations on the important features of the history and examination are based on expert opinion in review articles [BMJ Best Practice, 2021; Rivlin, 2022; BMJ Best Practice, 2022b; BMJ Best Practice, 2022a].  

Diagnostic manoeuvres

  • Romberg's test, the Dix-Hallpike manoeuvre, the head impulse test, and Unterberger's test are recommended on the basis of suggestions in a review article on the assessment of vertigo in general practice [Kuo, 2008]. 
  • The head impulse test and alternate cover test are also widely mentioned and recommended in the literature as part of the HINTS test (Head Impulse test for vestibulo-ocular reflex function, Nystagmus assessment, and Test of Skew deviation) — a group of oculomotor tests designed to improve bedside detection of stroke in people with acute vestibular syndrome [Edlow, 2016; Neuhauser, 2016; Venhovens, 2016; Brandt, 2017; Agarwal, 2022; Rivlin, 2022].
    • In a prospective cross-sectional study of 101 people with acute vestibular syndrome (vertigo, nystagmus, nausea/vomiting, intolerance of head movement, and gait unsteadiness) and at least one risk factor for stroke, findings of a normal head impulse test, direction-changing nystagmus in eccentric gaze, or skew deviation performed by a neuro-ophthalmologist was found to be 100% sensitive and 96% specific for stroke. The study authors acknowledged that a population without stroke risk factors may reduce the specificity of the HINTS results [Kattah, 2009]. 
    • Experts note that these bedside techniques may not be familiar to non-specialists in a primary care setting [Kattah, 2009; Venhovens, 2016; Rivlin, 2022], but suggested that training may be possible and useful. 

Romberg's test

  • The recommendation on carrying out Romberg's test and interpretation of the findings is based on expert opinion in review articles [Munro, 1995; Kuo, 2008; Turner, 2010].  

Dix-Hallpike manoeuvre

  • The instructions on how to perform and interpret the Dix-Hallpike manoeuvre are based on a US clinical practice guideline on benign paroxysmal positional vertigo (BPPV) [Bhattacharyya et al, 2017], a British Society of Audiology recommended procedure document on positioning tests [BSA, 2016], a consensus document on diagnostic criteria for BPPV [von Brevern, 2015], and expert opinion in review articles[BMJ Best Practice, 2021; BMJ Best Practice, 2022b].  
  • CKS advises caution for certain groups of people when considering the Dix-Hallpike manoeuvre and suggests referral for people with physical limitations based on a US clinical practice guideline on BPPV [Bhattacharyya et al, 2017] and a British Society of Audiology recommended procedure document on positioning tests [BSA, 2016].  
  • A prospective study of vertigo in primary care showed that the Dix-Hallpike manoeuvre is easy to introduce into daily practice. General practitioners involved in the study used it on 61% of people presenting with vertigo. The positive predictive value of a positive Hallpike test for a diagnosis of BPPV was 83.3%, with a negative predictive value of 52% [Hanley and O'Dowd, 2002].

Head impulse test

  • The details of the head impulse test procedure and advice to be cautious when considering its use for people with neck pathology are based on expert opinion in review articles [Hogue, 2015; Dommaraju and Perera, 2016; Rivlin, 2022].
  • Experts note that the head impulse test demonstrates the presence or absence of the vestibulo-ocular reflex and therefore can be used to assess peripheral vestibular function [Hogue, 2015; BMJ Best Practice, 2021].
    • A 2020 systematic review and meta-analysis showed that the HINTS examination used in isolation was not sufficiently accurate to rule out the presence of a stroke [Ohle, 2020]. 

Unterberger's test

  • The instructions on how to perform Unterberger's test and the explanation of the relevance of the findings are based on expert opinion in a textbook of clinical examination [Douglas et al, 2009] and the expert opinion of previous reviewers of this CKS topic.

Alternate cover test

  • The method for the alternate cover test and the implications of the examination findings are based on expert opinion in a review article on using the physical examination to diagnose patients with acute dizziness and vertigo [Edlow, 2016]. 

How should I determine the cause of vertigo?

  • Using findings from the history and examination, determine whether vertigo is likely to have a central or peripheral cause. Suspect a central cause of vertigo when the signs and symptoms do not match the features of any of the peripheral causes with reasonable accuracy.
  • Features increasing suspicion of a central cause of vertigo include:
    • Prolonged, severe vertigo (although this can also indicate vestibular neuronitis or Meniere's disease). 
    • New-onset headache or recent trauma.
    • Cardiovascular risk factors (consider the possibility of a posterior cerebral circulation stroke).
  • Features suggestive of a peripheral cause of vertigo include:
    • A normal neurological examination.
    • Severe nausea and vomiting.
    • Hearing loss — generally found in people with inner ear pathology, but note that it can also occur in stroke or intracranial tumours.
  • For more detail on differentiating features of peripheral and central vertigo, see Table 1.

Table 1. Summary of clinical features of peripheral and central vertigo

Clinical featuresPeripheralCentral
Postural stabilityCan walk, although may be unstable and may not wish to mobilise.Inability to stand up or walk even with the eyes open.
Hearing loss or tinnitusPossible with some causes (for example Meniere's disease, labyrinthitis).Uncommon but may occur (for example stroke or intracranial tumour).
Other neurological symptomsNo.Usually (for example cranial nerve dysfunction, visual disturbance, speech defects, dysarthria, weakness, sensory changes, memory loss, and gait ataxia). However, not all people with vertigo due to a stroke will have focal neurological signs. 
Nystagmus

Horizontal nystagmus with a torsional component that does not alter in direction when the gaze changes. Beats away from the affected side.

Disappears with fixation of the gaze.

Large amplitude nystagmus is usually only seen early in the course of Meniere's disease or vestibular neuronitis.

Direction-changing nystagmus on lateral gaze (right beating on right gaze, left beating on left gaze).

Purely vertical or torsional. 

Not suppressed by visual fixation. 

Non-fatiguable.

Commonly large amplitude nystagmus.

Head impulse testMay be positive with acute unilateral vestibular loss.Negative, indicating a normal vestibulo-ocular reflex.
Dix-Hallpike manoeuvreIn BPPV: latency of symptoms and nystagmus with fatiguability and habituation; severe vertigo. 

Abnormal response (for example vertical nystagmus without latency or fatiguability; direction not classical horizontal towards the downward ear).

Alternate cover test

 

Normal.Slight vertical correction (up on one side, down on the other) suggestive of a central lesion such as stroke. 
  • If a central cause of vertigo is suspected, see the Scenario: Central vertigo for more information on management.
  • If a peripheral cause of vertigo is suspected, use the history and examination findings to differentiate between conditions:
    • In benign paroxysmal positional vertigo (BPPV), episodes of vertigo are induced (rather than exacerbated) by moving the position of the head, and episodes last for seconds (less than 1 minute). Typical findings are elicited with the Dix-Hallpike manoeuvre. The nystagmus of BPPV is torsional but not sustained. For more information, see the CKS topic on Benign paroxysmal positional vertigo.
    • In vestibular neuronitis and labyrinthitis, vertigo is sudden in onset and severe. It usually persists for several days and gradually improves with time. The Head impulse test is positive. 
      • In vestibular neuronitis there is no hearing loss or tinnitus, but a spontaneous nystagmus may be present at the start of the episode.
      • People with labyrinthitis report hearing loss associated with vertigo, and tinnitus may be present, but they do not usually have the feeling of fullness in the ear that is described by people with Meniere's disease.
      • For more information, see the CKS topic on Vestibular neuronitis.
    • In Meniere's disease, episodes of vertigo occur spontaneously, are not provoked by position change, and last much longer than in BPPV (30 minutes to several hours). Tinnitus, fluctuating hearing loss, and fullness in the ear are present in Meniere's disease, but not usually in BPPV or vestibular neuronitis. There is no specific test for Meniere's disease. For more information, see the CKS topic on Meniere's disease.
  • If a peripheral cause is suspected but the underlying diagnosis remains in doubt, see the Scenario: Peripheral vertigo for more information on management.

Basis for recommendation

Approach to determining the cause of the vertigo

  • The recommendation to identify whether the cause of the vertigo is peripheral or central by using history and examination findings is based on suggestions by experts in review articles outlining an approach to the diagnosis of vertigo in general practice [Dommaraju and Perera, 2016; Muncie, 2017], other review articles on the symptoms of dizziness and vertigo [Brandt, 2017; Agarwal, 2022; Rivlin, 2022], a systematic review of bedside diagnosis in acute vestibular syndrome [Tarnutzer, 2011], and the expert opinion of previous reviewers of this CKS topic. It is important to accurately determine the nature of vertigo as central or peripheral to avoid misdiagnosis of serious conditions such as posterior circulation stroke [Edlow, 2016].

Clinical features of central and peripheral vertigo

The features of conditions causing central and peripheral vertigo are based on expert opinion in review articles [Dommaraju and Perera, 2016; Edlow, 2016; Venhovens, 2016; Omron, 2019; BMJ Best Practice, 2021] and a systematic review of bedside diagnosis in acute vestibular syndrome [Tarnutzer, 2011].

Using history and examination findings to differentiate between peripheral causes of vertigo

Management

Scenario: Central vertigo

From age 18 years onwards.

How should I manage central vertigo?

  • Always consider the possibility of a stroke in people with new onset unilateral hearing loss and vertigo.
  • If a central cause of vertigo is suspected, admit the person to hospital or urgently refer to a balance specialist (such as a neurologist or audiovestibular physician, depending on local service provision). The urgency of referral depends on the severity of symptoms and the suspected diagnosis.
  • Red flag symptoms requiring urgent brain imaging include:
    • Isolated, persistent (>24 hours) vertigo of hyperacute (seconds) onset. 
    • Normal head impulse test.
    • New onset headache.
    • New onset unilateral deafness.
    • Cranial nerve weakness or sensory loss, or limb weakness or sensory loss.
    • Severe ataxia.
  • Also consider admission the person if they have severe nausea and vomiting and are unable to tolerate oral fluids or symptomatic drug treatment.
    • Consider managing people with known migrainous vertigo at home. However, admit or refer people with suspected migrainous vertigo for investigation to confirm the diagnosis.
  • Consider offering short-term symptomatic drug treatment while the person is waiting to be admitted or seen by a specialist, but do not allow this to delay referral. 
    • To rapidly relieve severe nausea or vomiting associated with vertigo, consider giving buccal prochlorperazine, or a deep intramuscular injection of prochlorperazine or cyclizine.
    • To alleviate less severe nausea, vomiting, and vertigo, consider prescribing a short oral course of prochlorperazine or cinnarizine, cyclizine, or promethazine teoclate (antihistamines). 
    • For more information, see Prescribing information.
  • If the person's symptoms deteriorate and they have not yet been seen by a specialist, seek specialist advice. 

Basis for recommendation

Admission to hospital or urgent referral if a central cause of vertigo is suspected
  • Expert opinion in a review article on the diagnosis of vertigo in general practice advises that people with vertigo and other neurological features are likely to have brainstem disease, and should be referred urgently [Muncie, 2017]. This is consistent with other expert opinion which states that if a serious neurological disorder is suspected, the person should be referred immediately [Agarwal, 2022; Rivlin, 2022]. In addition, tests such as computed tomography (CT), magnetic resonance imaging (MRI), or magnetic resonance angiography (MRA) are required if features suggesting a central cause such as examination inconsistent with a peripheral lesion, prominent risk factors for stroke, neurological symptoms or signs, or headache are present [Dommaraju and Perera, 2016].  
  • The recommendation to admit a person with severe nausea and vomiting (that cannot be managed in the person's home) is pragmatic and is based on what CKS considers to be good clinical practice. 

Although evidence is lacking on the prophylactic and acute treatment of migrainous vertigo, some experts suggest that it can be treated similarly to standard migraine [van Vugt, 2017; Muncie, 2017; Rivlin, 2022]. However, others suggest that the diagnosis should be made cautiously, particularly in primary care, as brainstem vascular events can resemble the symptoms of migrainous vertigo. It is advised that most people with new-onset headache in addition to vertigo will require hospital admission, unless there is a history of recurrent similar episodes, to exclude other potentially more serious diagnoses [Seemungal, 2008; Barraclough, 2009].

Symptomatic drug treatment 
  • CKS found no good quality evidence of benefit for the different symptomatic treatment options. However, the recommended drugs are all licensed for nausea, vomiting, and vertigo [ABPI, 2018a; ABPI, 2021a; ABPI, 2021b; ABPI, 2022a].
Seeking specialist advice if symptoms deteriorate
  • This recommendation is pragmatic and is based on what CKS considers to be good clinical practice.

Scenario: Peripheral vertigo

From age 18 years onwards.

How should I manage a person with peripheral vertigo?

  • Assess the person's symptoms, medical history, and clinical findings. If the person has features suggestive of a particular cause of peripheral vertigo, manage appropriately. For more information, see the relevant CKS topics on Benign paroxysmal positional vertigo, Meniere's disease, and Vestibular neuronitis.
  • If a peripheral cause of vertigo is being considered, admit to hospital or urgently refer (using clinical judgement depending on type and severity of symptoms) to an appropriate specialist (depending on local service provision) if the person has:
    • Severe nausea and vomiting and is unable to tolerate oral fluids or symptomatic drug treatment. 
    • Very sudden onset of vertigo (within seconds) that is not provoked by positional change and is persistent.
    • Central neurological symptoms or signs (for example new type of headache [especially occipital], gait disturbance, truncal ataxia, and vertical nystagmus).
    • Acute deafness without other typical features of Meniere's disease.
  • For all other people with vertigo of undetermined cause — refer to a balance specialist (ear, nose, and throat specialist, audiovestibular physician, neurologist, or care of the elderly physician with a special interest — depending on local service provision). The urgency of referral will depend on the person's symptoms, clinical findings, and clinical judgement.
  • While awaiting referral, consider offering symptomatic drug treatment with prochlorperazine or cinnarizine, cyclizine, or promethazine teoclate (antihistamines) for no longer than 1 week. 
    • To rapidly relieve severe nausea or vomiting associated with vertigo, consider giving buccal prochlorperazine, or a deep intramuscular injection of prochlorperazine or cyclizine. 
    • To alleviate less severe nausea, vomiting, and vertigo, consider prescribing a short oral course of prochlorperazine or cinnarizine, cyclizine, or promethazine teoclate (antihistamines).
  • If the person's symptoms deteriorate, seek specialist advice.

Basis for recommendation

Assess symptoms, medical history and clinical findings
Admission and urgent referral
  • The recommendation on arranging admission for a person unable to tolerate oral fluids or symptomatic drug treatment is pragmatic, based on what CKS considers to be good clinical practice.
  • The recommendations on sudden onset of vertigo, central symptoms or signs, and acute deafness are based on expert opinion from review articles on the diagnosis of vertigo in general practice or emergency assessment settings [Agarwal, 2022; BMJ Best Practice, 2022a; Rivlin, 2022], and red flag features for urgent referral for people with acute vertigo: 
    • Hyperacute onset of symptoms reaching maximum intensity in several minutes, neurological symptoms and signs, purely vertical or torsional nystagmus, acute unilateral deafness, and new headache are 'red flags', indicative of a brainstem stroke or other central cause [BMJ Best Practice, 2021; Agarwal, 2022; Rivlin, 2022].
Referral for people with vertigo of undetermined cause
  • The recommendation to refer people for whom vertigo has an undetermined cause is based on expert opinion in review articles on an approach to vertigo in general practice in which referral is recommended if the diagnosis is not clear [Dommaraju and Perera, 2016; BMJ Best Practice, 2021]. CKS recommends using clinical judgement regarding whom, and with what urgency, to refer, based on what it considers to be good clinical practice. 
Symptomatic drug treatment
  • CKS found no good quality evidence of benefit for the different symptomatic treatment options. However, these drugs are all licensed for use in people with labyrinthine disorders, and for nausea, vomiting, and vertigo [ABPI, 2018a; ABPI, 2021a; ABPI, 2021b; ABPI, 2022a].  
  • Benzodiazepines are not recommended because although some experts advocate their use, CKS found no evidence to support this and they are not licensed for treating nausea, vomiting, or vertigo [BNF, 2022]. They also have the potential for dependence [Dommaraju and Perera, 2016]. 
  • Expert opinion in review articles suggests that symptomatic drug treatment should only be used in the short term, because prolonged use may delay vestibular compensation for peripheral vertigo in conditions such as vestibular neuronitis [Wipperman, 2014; van Vugt, 2017]. 
Seek specialist advice if symptoms deteriorate
  • This recommendation is pragmatic and is based on what CKS considers to be good medical practice. 

Prescribing information

Important aspects of prescribing information relevant to primary healthcare are covered in this section specifically for the drugs recommended in this CKS topic. For further information on contraindications, cautions, drug interactions, and adverse effects, see the electronic Medicines Compendium (eMC), or the British National Formulary (BNF).

Cinnarizine

What dosage of cinnarizine should I prescribe?

For vestibular symptoms, prescribe oral cinnarizine 30 mg three times a day [ABPI, 2021a; BNF, 2022].

What are the contraindications and cautions when prescribing cinnarizine?

  • Do not prescribe cinnarizine if the person:
    • Is hypersensitive to cinnarizine or any of its excipients.
    • Has porphyria.
    • Has severe liver disease (there is an increased risk of coma).
  • Prescribe cinnarizine with caution if the person has:
    • Parkinson’s disease – give only if the advantages outweigh the risk of disease exacerbation.
    • Hepatic or renal impairment.
    • Epilepsy.
    • Prostatic hypertrophy.
    • Pyloroduodenal obstruction.
    • Susceptibility to angle closure glaucoma.
    • Urinary retention.

 [ABPI, 2021a; BNF, 2022]

What are the adverse effects of cinnarizine?

  • Adverse effects of cinnarizine are more common in older people and include drowsiness, nausea, dyspepsia, and weight gain.
  • Less common adverse effects include:
    • Anaphylaxis, angio-oedema.
    • Dyskinesia, extrapyramidal disorder, Parkinsonism, tremor, convulsions.
    • Cholestatic jaundice.
    • Palpitations.
    • Bronchospasm.
    • Subacute cutaneous lupus erythematosus, lichen planus, photosensitivity reactions, rashes.
    • Angle-closure glaucoma.
    • Confusion, depression.

 [ABPI, 2021a; BNF, 2022]

What drug interactions occur with cinnarizine?

  • Concurrent use of cinnarizine and alcohol, CNS depressants, or tricyclic antidepressants may result in increased sedative effects [ABPI, 2021a]. Advise that this may influence the ability to perform skilled tasks such as driving [BNF, 2022].  
  • The use of phenelzine in conjunction with cinnarizine increases the risk of antimuscarinic adverse effects [BNF, 2022].  
  • Avoid using cinnarizine within 4 days of skin testing as it may influence the results [ABPI, 2021a].  

Cyclizine

What dosage of cyclizine should I prescribe?

  • For nausea, vomiting, vertigo, or labyrinthine disorders, prescribe cyclizine 50 mg orally up to three times a day [ABPI, 2018a; BNF, 2022]. 
  • If the oral route is not appropriate, cyclizine 50 mg by intramuscular injection can be given up to three times a day [ABPI, 2018b; BNF, 2022].

What are the contraindications and cautions when prescribing cyclizine?

  • Do not prescribe cyclizine to people with:
    • Hypersensitivity to cyclizine or its excipients.
    • Severe liver disease — increased risk of coma.
    • Porphyria.
  • Prescribe cyclizine with caution to people with:
    • Prostatic hypertrophy, urinary retention, susceptibility to angle-closure glaucoma, and pyloroduodenal obstruction.
    • Hepatic disease.
    • Epilepsy.
    • Severe heart failure or acute myocardial infarction — cyclizine may cause a fall in cardiac output associated with increases in heart rate, mean arterial pressure, and pulmonary wedge pressure.
    • Phaeochromocytoma.

[ABPI, 2018a; BNF, 2022]

What are the adverse effects of cyclizine?

  • Drowsiness is a significant adverse effect with most of the older antihistamines (such as cyclizine), especially with high doses or in the elderly.
  • Other adverse effects include:
    • Psychiatric — restlessness, nervousness, euphoria, disorientation, insomnia, and auditory and visual hallucinations.
    • Neurological — headache, dystonia, dyskinesia, extrapyramidal motor disturbances, tremor, seizures, dizziness, somnolence and decreased consciousness, speech disorders (transient), paraesthesia, and generalized chorea.
    • Cardiovascular — tachycardia, palpitations, arrhythmias, hypertension, and hypotension.
    • Respiratory — bronchospasm and apnoea.
    • Gastrointestinal and hepatic — dry mouth, nose and throat; constipation; increased gastric reflux; nausea, vomiting, and diarrhoea; stomach pain; loss of appetite; hepatic dysfunction; cholestatic jaundice and hepatitis.
    • Skin — rashes, urticaria, angio-oedema, allergic skin reactions, and fixed drug eruption photosensitivity.
    • Musculoskeletal — twitching and muscle spasms.
    • Immune system — hypersensitivity reactions, including anaphylaxis.
    • Blood and lymphatic system — agranulocytosis, haemolytic anaemia, leucopenia, and thrombocytopenia.
    • Others — tinnitus, blurred vision and oculogyric crisis, and urinary retention.

[ABPI, 2018a; BNF, 2022]

What drug interactions occur with cyclizine?

  • Important drug interactions with cyclizine include:
    • Alcohol — the anti-emetic effect of cyclizine may increase the toxic effects of alcohol.
    • Antimuscarinic drugs — there is a risk of increased antimuscarinic adverse effects when cyclizine is given with other antimuscarinic drugs. 
    • Central nervous system (CNS) depressant drugs — cyclizine may have additive effects with other CNS depressants, such as opioid analgesics.
    • Ototoxic drugs — cyclizine may disguise signs indicating the onset of damage caused by ototoxic drugs (such as aminoglycoside antibiotics).

[ABPI, 2018a; BNF, 2022]

Prochlorperazine

What dosage of prochlorperazine should I prescribe?

  • For vertigo, prescribe prochlorperazine 5 mg orally three times a day (maximum dose 30 mg daily) [ABPI, 2022a].  
  • If the oral route is not appropriate, consider prescribing either:
    • Prochlorperazine buccal tablets 3–6 mg twice a day (to be placed high in the buccal cavity and allowed to dissolve) [ABPI, 2019], or 
    • Prochlorperazine 12.5 mg by deep intramuscular injection followed by oral medication after an interval of 6 hours, if required [ABPI, 2021c]. 

What are the contraindications and cautions when prescribing prochlorperazine?

  • Do not prescribe prochlorperazine to people with:
    • Hypersensitivity to prochlorperazine or its excipients.
    • Agranulocytosis.
    • A history of angle closure glaucoma.
    • Prostate hypertrophy.
    • Myasthenia gravis.
    • Heart failure.
    • Hypothyroidism.
    • Parkinson's disease.
    • History of jaundice.
    • Liver or renal dysfunction.
    • Phaeochromocytoma.
  • Prescribe prochlorperazine with caution to:
    • People with epilepsy or a history of seizures — close monitoring is required in this group of people as prochlorperazine may lower the seizure threshold.
    • Elderly people — use with caution, especially during very hot or cold weather due to the risk of hyper- or hypothermia.
    • People with cardiovascular disease or family history of QT prolongation — cases of QT interval prolongation have been very rarely reported with prochlorperazine. An alternative anti-emetic should be considered for people with predisposing factors for ventricular arrhythmias, or they should be carefully monitored (check electrolytes and ECG), particularly during the initial phase of treatment.
      • Cardiac disease; metabolic abnormalities such as hypokalaemia, hypocalcaemia, or hypomagnesaemia; starvation; alcohol misuse; and concurrent treatment with other drugs known to prolong the QT interval may predispose people to ventricular arrhythmias.

[ABPI, 2022a; BNF, 2022]

What are the adverse effects of prochlorperazine?

  • Extrapyramidal symptoms
    • These depend on the dose and the susceptibility of the individual person:
      • Parkinsonian symptoms (including tremor) may occur more commonly in adults or the elderly and may appear gradually.
      • Dystonia (abnormal face and body movements) and dyskinesia are more common in young people and can occur after only a few doses.
      • Akathisia (restlessness) characteristically occurs after large initial doses.
      • Tardive dyskinesia (rhythmic, involuntary movements of tongue, face, and jaw) usually develops on long-term treatment or with high doses.
  • Endocrine disorders
    • Hyperprolactinaemia which may result in galactorrhoea, gynaecomastia, impotence, and amenorrhoea has been reported following treatment with prochlorperazine.
  • Cardiac disorders
    • Cardiac arrhythmias, including atrial arrhythmia, atrioventricular block, ventricular fibrillation, and ventricular tachycardia (rare), have been reported. QT prolongation, sudden death, cardiac arrest, and Torsades de pointes have also occurred following treatment with prochlorperazine.
    • Pre-existing cardiac disease, family history of QT prolongation, increasing age, hypokalaemia, and concurrent use of other drugs known to prolong the QT interval may increase the likelihood of these effects.
  • Blood and lymphatic system disorders
    • Mild leucopenia occurs in up to 30% of people on high doses of prochlorperazine for a prolonged period of time.
    • Agranulocytosis may occur rarely, but it is not related to the dose. If unexplained infections or fever occur, immediate haematological investigation is required.
    • Cases of venous thromboembolism have also been reported with prochlorperazine.
  • Other adverse effects include:
    • Neurological disorders — drowsiness, apathy, agitation, excitement, insomnia, convulsions, dizziness, headache, and confusion.
    • Antimuscarinic effects — dry mouth, constipation, difficulty with micturition, blurred vision, and precipitation of angle-closure glaucoma (very rare).
    • Skin and tissue disorders — photosensitization, contact sensitization, rashes, and purplish pigmentation of the skin.
    • Hepatobiliary disorders — jaundice (including cholestatic).
    • Eye disorders — corneal and lens opacities and purplish pigmentation of the cornea, conjunctiva, and retina.
    • Neuroleptic malignant syndrome (potentially fatal) — symptoms include changes in conscious level and mental status, unexplained fever, hyperthermia, autonomic dysfunction, and muscle rigidity.

[ABPI, 2020; ABPI, 2022a; BNF, 2022]

What drug interactions occur with prochlorperazine?

  • Alcohol — advise the person to avoid taking alcohol whilst taking prochlorperazine.
    • The sedative effects of alcohol on driving and operating heavy machinery may be enhanced by prochlorperazine.
  • Antimuscarinic drugs — there is a risk of increased antimuscarinic adverse effects when prochlorperazine is given with other antimuscarinic drugs.
  • Antiepileptic drugs — concurrent use of prochlorperazine and antiepileptic drugs may lower the seizure threshold because of liver enzyme induction. 
  • Antihypertensive drugs — the hypotensive effect of most antihypertensive drugs (particularly alpha-adrenoceptor blockers and calcium channel blockers) may be increased by prochlorperazine.
  • Cimetidine — plasma concentrations of prochlorperazine may be increased or decreased by cimetidine. Excessive sedation may occur and it may be necessary to reduce the dose of prochlorperazine.
  • Central nervous system (CNS) depressants— the CNS depressant actions of prochlorperazine may be increased by barbiturates, opioid analgesics, anxiolytics, and hypnotics, raising the risk of respiratory depression.
  • Drugs that prolong the QT interval — there is an increased risk of ventricular arrhythmias when prochlorperazine is used concurrently with drugs that prolong the QT interval, for example, anti-arrhythmics, sotalol, antidepressants (tricyclics, citalopram, and escitalopram), antihistamines (terfenadine), methadone, and risperidone.
  • Lithium — there is an increased risk of extrapyramidal adverse effects and possibly neurotoxicity when prochlorperazine is given with lithium. 
  • Sulfonylureas — the hypoglycaemic effect of sulfonylureas (such as gliclazide) may be antagonized by prochlorperazine. Dose adjustment of the sulfonylurea may be required.

[ABPI, 2020; ABPI, 2022a; Preston, 2023]

Promethazine teoclate

What dosage of promethazine teoclate should I prescribe?

Prescribe promethazine teoclate 25 mg orally at night. The dose may be increased to 100 mg daily [ABPI, 2021b; BNF, 2022].  

What are the contraindications and cautions when prescribing promethazine teoclate?

  • Promethazine teoclate should not be used in people with:
    • Hypersensitivity to promethazine, its excipients, or other phenothazines.
    • Central nervous system (CNS) depression of any cause.
    • Exposure to monoamine oxidase inhibitors within the previous 14 days.
    • Severe liver disease — increased risk of coma.
  • Promethazine teoclate should be used with caution in people with:
    • Hepatic or renal impairment.
    • Severe coronary artery disease.
    • Urinary retention or prostatic hypertrophy.
    • Angle-closure glaucoma.
    • Pyloroduodenal obstruction.
    • Epilepsy.
    • Asthma, bronchitis, or bronchiectasis — promethazine teoclate may thicken or dry lung secretions and impair expectoration.
    • In addition phenothiazine derivatives may potentiate QT interval prolongation increases the risk of ventricular arrhythmias including Torsade de pointes. QT prolongation is exacerbated, in particular, in the presence of bradycardia, hypokalaemia, and drug induced QT prolongation. The manufacturer suggests that if the clinical situation permits, medical and laboratory evaluations should be performed to rule out possible risk factors before initiating treatment with a phenothiazine derivative and when necessary during treatment.

 [ABPI, 2022b; BNF, 2022]

What are the adverse effects of promethazine teoclate?

Adverse effects of promethazine include:

  • Neurological — dizziness, confusion, restlessness, headaches, nightmares, sedation (affected people should not drive or operate heavy machinery), tremor, muscle spasms and tic-like movements of the head and face, restless legs syndrome, and extrapyramidal effects.
  • Antimuscarinic effects — blurred vision, dry mouth, and urinary retention.
  • Skin — rash and photosensitivity.
  • Gastrointestinal — anorexia, gastric irritation, and jaundice (rare).
  • Cardiovascular — palpitations, hypotension, and arrhythmias.

 [ABPI, 2021b; BNF, 2022]

What drug interactions occur with promethazine?

  • Drug interactions with promethazine include:
    • Opioid analgesics — sedative effects may be enhanced when promethazine is given with opioid analgesics.
    • Alcohol — sedative effects may be increased by the combination of promethazine and alcohol.
    • Antimuscarinic drugs, tricyclic antidepressants, sedatives, and hypnotics — concomitant use with promethazine enhances the antimuscarinic and/or sedative action of these drugs.
  • Promethazine has the potential to interact with immunological pregnancy tests (may give false-positive or false-negative results). It may also give a false negative result with skin tests by inhibiting the cutaneous histamine response — discontinue 72 hours in advance.

 [ABPI, 2021b; BNF, 2022; Preston, 2023]

Supporting evidence

This CKS topic is largely based on expert opinion in review articles such as BMJ Best Practice: Assessment of balance disorders, Assessment of Dizziness, and Overview of vertigo [BMJ Best Practice, 2021; BMJ Best Practice, 2022b; BMJ Best Practice, 2022a]. The rationale for the assessment and management of a person with vertigo is based on expert opinion in articles from peer-reviewed journals [Muncie, 2017; Omron, 2019; Agarwal, 2022; Rivlin, 2022; Stanton, 2022].

How this topic was developed

This section briefly describes the processes used in developing and updating this topic. Further details on the full process can be found in the About Us section and on the Clarity Informatics website.

Search strategy

A literature search was conducted for guidelines, systematic reviews and randomized controlled trials on primary care management of vertigo.

Search dates

August 2017 - November 2022

Key search terms

Various combinations of searches were carried out. The terms listed below are the core search terms that were used for Medline.

  • exp vertigo/, vertigo*.tw.,
  • vestibular neuritis.tw., benign paroxysmal positional.tw., BP$V.tw., acoustic neuroma/, motion sickness.tw., meniere disease/, meniere's disease.tw., labyrinthitis/, labyrinthitis.tw., vestibular neuronitis.tw., vestibular neuronitis/, vestibulopathy.tw., neurolabyrinthitis.tw., acute unilateral peripheral vestibulopathy.tw.
  • betahistine/, betahistine.tw., prochlorperazine/, prochlorperazine.tw., antihistamine/, antihistamines.tw., cyclizine/, cyclizine.tw., cinnarizine/, cinnarizine.tw., promethazine/, promethazine.tw.

Sources of guidelines

Sources of systematic reviews and meta-analyses

  • The Cochrane Library:
    • Systematic reviews
    • Protocols
    • Database of Abstracts of Reviews of Effects
  • Medline (with systematic review filter)
  • EMBASE (with systematic review filter)

Sources of health technology assessments and economic appraisals

Sources of randomized controlled trials

  • The Cochrane Library:
    • Central Register of Controlled Trials
  • Medline (with randomized controlled trial filter)
  • EMBASE (with randomized controlled trial filter)

Sources of evidence based reviews and evidence summaries

Sources of national policy

Patient experiences

Sources of medicines information

The following sources are used by CKS pharmacists and are not necessarily searched by CKS information specialists for all topics. Some of these resources are not freely available and require subscriptions to access content.

Stakeholder engagement

Our policy

The external review process is an essential part of CKS topic development. Consultation with a wide range of stakeholders provides quality assurance of the topic in terms of:

  • Clinical accuracy.
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Principles of the consultation process

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  • To participate, an individual must declare whether they have any competing interests or not. If they do not declare whether or not they have competing interests, their comments will not be considered.
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  • Comments are accepted in any format that is convenient to the reviewer, although an electronic format is encouraged.
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  • Discussion with an individual or an organization about the CKS response to their comments is only undertaken in exceptional circumstances (at the discretion of the Clinical Editor or Editorial Steering Group).
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  • All reviewers are invited to be acknowledged on the website. All reviewers are given the opportunity to feedback about the external review process, enabling improvements to be made where appropriate.

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  • Key stakeholders identified by the CKS team are invited to comment on draft CKS topics. Individuals and organizations can also register an interest to feedback on a specific topic, or topics in a particular clinical area, through the Getting involved section of the Clarity Informatics website.
  • Stakeholders identified from the following groups are invited to review draft topics:
    • Experts in the topic area.
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Clarity Informatics has enlisted the support and involvement of patients and lay persons at all stages in the process of creating the content which include:

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Our lay and patient involvement includes membership on the editorial steering group, contacting expert patient groups, organizations and individuals.

Evidence exclusion criteria

Our policy

Scoping a literature search, and reviewing the evidence for CKS is a methodical and systematic process that is carried out by the lead clinical author for each topic. Relevant evidence is gathered in order that the clinical author can make fully informed decisions and recommendations. It is important to note that some evidence may be excluded for a variety of reasons. These reasons may be applied across all CKS topics or may be specific to a given topic.

Studies identified during literature searches are reviewed to identify the most appropriate information to author a CKS topic, ensuring any recommendations are based on the best evidence. We use the principles of the GRADE and PICOT approaches to assess the quality of published research. We use the principles of AGREE II to assess the quality of published guidelines.

Standard exclusions for scoping literature:

  • Animal studies
  • Original research is not written in English

Possible exclusions for reviewed literature:

  • Sample size too small or study underpowered
  • Bias evident or promotional literature
  • Population not relevant
  • Intervention/treatment not relevant
  • Outcomes not relevant
  • Outcomes have no clear evidence of clinical effectiveness
  • Setting not relevant
  • Not relevant to UK
  • Incorrect study type
  • Review article
  • Duplicate reference

Organizational, behavioural and financial barriers

Our policy

The CKS literature searches take into consideration the following concepts, which are discussed at the initial scoping of the topic.

  • Feasibility
    • Studies are selected depending on whether the intervention under investigation is available in the NHS and can be practically and safely undertaken in primary care.
  • Organizational and Financial Impact Analysis
  • Studies are selected and evaluated on whether the intervention under investigations may have an impact on local clinical service provision or national impact on cost for the NHS. The principles of clinical budget impact analysis are adhered to, evaluated and recorded by the author. The following factors are considered when making this assessment and analysis.
    • Eligible population
    • Current interventions
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    • Cost of the current or new intervention mix
    • Impact on other costs
    • Condition-related costs
    • In-direct costs and service impacts
    • Time dependencies
  • Cost-effectiveness or cost-benefit analysis studies are identified where available. 

We also evaluate and include evidence from NICE accredited sources which provide economic evaluations of recommendations, such as NICE guidelines. When a recommended action may not be possible because of resource constraints, this is explicitly indicated to healthcare professionals by the wording of the CKS recommendation.

Declarations of interest

Our policy

Clarity Informatics requests that all those involved in the writing and reviewing of topics, and those involved in the external review process to declare any competing interests. Signed copies are securely held by Clarity Informatics and are available on request with the permission of the individual. A copy of the declaration of interest form which participants are asked to complete annually is also available on request. A brief outline of the declarations of interest policy is described here and full details of the policy is available on the Clarity Informatics website. Declarations of interests of the authors are not routinely published, however competing interests of all those involved in the topic update or development are listed below. Competing interests include:

  • Personal financial interests
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Although particular attention is given to interests that could result in financial gains or losses for the individual, competing interests may also arise from academic competition or for political, personal, religious, and reputational reasons. An individual is not obliged to seek out knowledge of work done for, or on behalf of, the healthcare industry within the departments for which they are responsible if they would not normally expect to be informed.

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Any individual (or organization) involved in developing, reviewing, or commenting on clinical content, particularly the recommendations should declare competing interests. This includes the authoring team members, expert advisers, external reviewers of draft topics, individuals providing feedback on published topics, and Editorial Steering Group members. Declarations of interest are completed annually for authoring team and editorial steering group members, and are completed at the start of the topic update and development process for external stakeholders.

Competing interests declared for this topic:

None.

References

  • ABPI (2018a) SPC for Cyclizine 50mg Tablets. Electronic Medicines Compendium. Datapharm Communications Ltd. https://www.medicines.org.uk/emc [Free Full-text]
  • ABPI (2018b) SPC for cyclizine lactate 50 mg/mL injection. Electronic Medicines Compendium (EMC). Datapharm Communications Ltd. [Free Full-text]
  • ABPI (2019) SPC for prochlorperazine 3 mg buccal tablets. Electronic Medicines Compendium. Datapharm Communications Ltd. https://www.medicines.org.uk/emc [Free Full-text]
  • ABPI (2020) SPC for prochlorperazine tablets BP 5 mg. Electronic Medicines Compendium. Datapharm Communications Ltd. https://www.medicines.org.uk/emc [Free Full-text]
  • ABPI (2021a) SPC for cinnarizine 15 mg tablets. Electronic Medicines Compendium. Datapharm Communications Ltd. https://www.medicines.org.uk/emc [Free Full-text]
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