DIAGNOSIS,

PATHOPHYSIOLOGY
AND MANAGEMENT OF
VERTIGO

Meiti Frida, MD
Neurology Department M Djamil Hospital/Andalas
University

ngeran Beach Hotel , Jan 19th. 2013

OUTLINE
1. Introduction
Definition vertigo
Etiology

2. Pathophysiology vertigo
3. Diagnosis vertigo
4. Treatment vertigo

DEFINITION
Vertigo
-Common medical problem
-30% of people average 65 years
-20% of all older person seek medical
advice
Vertigo : The sensation of spinning or
evolving
while the body is stationary with respect
to the earth or surrounding

ETIOLOGY
1.Otology
24 61 % case
Benign Paroxysmal Positional Vertigo
(BPPV)
Meniere Disease
Parese N VIII
Otitis media

2.

Neurology
23 30% case
Cerebrovascular disorder (TIA ) Stroke
Neuropathy ataxia
Multiple sclerosis
Servical disorder
Tumor (acustic neuroma)
Chiari malformation
Cerebellum Disorder

3. Systemic Cause
33% cardiovaskuler disorder
Blood pressure
Arithmia cordis
Uremia
Glycemia
Infection
Drug intoxication : Nifedipin,
benzodiazepin, xanax

4. Psychiatry
> 50 % case
Depression
Fobia
Anxietas
Psichosomatic

Pathophysiology Vertigo
Receptor

Eye
Vestibuler
Proprioceptiv
e

Data
Processing

CNS

Efector

Scletal Muscle
Eye
Servical
Body
Extremities

NORMAL PROCESSING
Vestibular system
visus
Propriocep tive

Sensory
Information
= coordinated

Central

= known pattern

Oculomotor
central

stabilization of visual field

Muscles of the
body
static and kinetic equilibrium

Head
Acceleratio
n

Endolymph
Displacement

Head Angular
Velocity
Cilia
Bending

Cupular
Angle

Receptor Cell
Potential
Synaptic
Action
Generator
potential
Primary
afferent
action
potential
CNS
Ket :
CNS : central Nervous System
precept
VOR : Vestibulo Ocular Reflex

io

VOR

postur
e

DIAGNOSING VERTIGO
Anamnesis
What symptom you have for example wether you
feel light headed or if your surrounding are spinning
How often your symptom occur
How long you symptoms usually lost for
If your symptom are affecting your daily activities
for example, wether you are unable to walk during
on episode of vertigo
Have a family history of migraine or meniere
disease
Have recently had an infection or head injury

Physical examination
Blood pressure : hipotensi orthostatic
Heart rate rythm
Bruit carotis
Neurology examination
Awarness
Nn Cranialis
Motoric
Sensoric
Serebelum

Other Test
Hallpike`s
Manouvre
Manuver Valsava
Nylen Barany Test
Calori Test
Hallpike`s Manouvre

 Hearing test: Tinnitus,

Hearing Loss
Audiometry Test
Tuning fork Test

MRI scan : Acoustic

Neuroma
Romberg test
BAEP

Romberg test

I. VERTIGO
Vertigo
Otogenik

Neurogenik

1. Type

Rotatory
directional
horizontal

Non rotational

2. Direction

Rotatory

Horizontal,
rotatory
scotoma

II. Physical Diagnosis

a.Position
changes
b. Gait
disturbanc
e

Influence by
head
position/body

Influence by
neck motion
often

Rarely
Rarely

c. Autonoum Always
dysfunctio
n
Tinnitus,
d. Others
hearing loss
symptoms Deficit
neurologic focal
(-)

Impaired
consciousness
Deficit
neurologic
focal (+)

III. Nystagmus examination

a.Direction

Indirection

Bidirection

b. Type

Horizontal or
rotatory
horizontal

Rotatory
vertikal, down
beat, up beat

c. Eye fixation

blocking

Non blocking

d. Nystagmus
positional

Repeat Difficult Easy repeated

e.

sinusoid

Saccadic/ataxic

Unilateral
weakness

Bilateral
weakness

Eye
tracking

f. Calory

IV. Vestibulo spinal examination

a. Romberg test
Mata terbuka
Mata tertutup

Normal
abnormal

Abnormal
Abnormal

b. Writing test

Deviasi abnormal

Ataxia / wave

c. Ataxia

none

often

d. Finger to finger Normal

test

Abnormal

e. Past pointing
test

Abnormal both
hands

Abnormal side of
lesion

f. Stepping

Deviation of side
of lesion

Erratic deviation

g. Walking

eye closed
There are
deviation

Eye closed and

open are deviation

Treatment of Vertigo

Depend upon the subtype and cause

identified
Supportif
Simptomatic
Causatif
Operatif

I. Symptomatic Treatment
Anti histamine
Treatment
Dymen hydrinate
3 x 50mg/day
Cinnarizine
3 x 25mg/day
Ca-entry blocker
Flunarizine
3 x 5- 10mg/day
Histaminic
Betahistine (merislon)
3 x 8mg/day
Fenotiazine
Chlorpromazine
3 x 25mg/day
Metoclopramide
Primperan
3 x 10mg/day

Causative Treatment
Anti platelet agregation
Operatif
Tumor
Spondylosis servikalis

Epilepsi
Phenitoin
Carbamazepin

Migrain
Ergotamine
Flunarizine

Rehabilitatif Treatment
- Metode Brandt-Daroff
- Gait exercise

The Effect of Betahistine Mesylate

as a Treatment to Vertigo Induced
by Inner Ear Ischemia

ZI-MING W, ET AL. THE EFFECT OF BETAHISTINE MESYLATE AS A TREATMENT TO VERTIGO INDUCED BY INNER
EAR ISCHEMIA. CHINESE SCIENTIFIC JOURNAL OF HEARING & SPEECH REHABILITATION 2007

Objective
To observe the effects of betahistine mesylate as a treatment to
benign positional paroxysmal vertigo (BPPV), posterior circulation
ischemia (PCI), migrainous vertigo (MV) and teenager benign
paroxysmal vertigo and to study the causal relationships of dosages
between betahistine mesylate 6 mg & 12 mg
Method
90 cases BPPV, PCI & MV @ 30 cases per disease & devided into
2 groups @ 15 cases per group.
Group 1: betahistine mesylate 6 mg 3x perday.
Group 2 : betahistine mesylate 12 mg 3x perday
duration of treatment for 1 month
Zi-ming W, et al. The Effect of Betahistine Mesylate as a Treatment to Vertigo Induced by
Inner Ear Ischemia. Chinese Scientific Journal of Hearing & Speech REhabilitation 2007

Total pasien n= 90
BPPV
30 pasien

PCI
30 pasien

MV
30 pasien

Grouping of patients

MRS 6 mg
MRS 6 mg
MRS 12 mg
MRS 12 mg
MRS 6 mgMRS 12 mg
15 patients
15 patients
15 patients
15 patients
15 patients
15 patients

Parameter
High stimulating rate of auditory brainstem
response (ABR)
Dizziness handicap inventory (DHI)
ABR & DHI be evaluated & compared before & after
adminstrationZi-ming
of betahistine
mesylate
W, et al. The Effect of Betahistine Mesylate as a Treatment to Vertigo Induced by
Inner Ear Ischemia. Chinese Scientific Journal of Hearing & Speech REhabilitation 2007

Penggunaan Betahistine Mesylate 12 mg memberikan perbaikan lebih signifikan

dibandingkan penggunaan 6 mg pada pasien dengan gangguan ABR

p<0.01

p<0.05

p<0.01

Kesimpulan: Efikasi ditunjukan oleh kedua grup baik 6 mg maupun 12 mg. Namun pada grup yang diberikan
Betahistine Mesylate 12 mg, 3 x 1 selama 1 bulan, terlihat perbedaan yang signifikan dibandingkan dengan 6 mg.
Zi-ming W,et al. The effect of betahistine mesylate as a treatment to vertigo induced by inner ear ischemia. 2007

Penggunaan Betahistine Mesylate 12 mg memberikan perbaikan lebih signifikan

dibandingkan penggunaan 6 mg dalam meningkatkan kualitas hidup pasien vertigo
sever
e

mild

n=90
Kesimpulan: Efikasi ditunjukan oleh kedua grup baik 6 mg maupun 12 mg. Namun pada grup yang diberikan
Betahistine Mesylate 12 mg, 3 x 1 selama 1 bulan, terlihat perbedaan yang signifikan dibandingkan dengan 6 mg
dalam menurunkan tingkat keparahan vertigo dengan pengukuran DHI.
Zi-ming W,et al. The effect of betahistine mesylate as a treatment to vertigo induced by inner ear ischemia. 2007

Betahistine Mesylate 12mg, 3 x sehari ditoleransi dengan

baik oleh pasien Vertigo dan Dizziness.

Dari 2.254 pasien hanya 26 pasien (1.15%) yang melaporkan efek samping. Dosis 18mg
-36mg/hari

( Japan Pharmaceuticals Reference, 2009 )

Conclusion
Vertigo is public health problem
especially in the elderly
Need anamnesis and examination
as well as the etiology of vertigo
Treatment depends on the subtype
and cause