eMedicine Specialties > Emergency Medicine > Neurology
Central Vertigo: Treatment & Medication
Updated: Nov 6, 2009
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
- Multimedia
Treatment
Emergency Department Care
First, distinguish true vertigo from disequilibrium and other forms of dizziness. Ascertaining this history from patients sometimes requires patience and persistence. Once the presence of vertigo or disequilibrium has been confirmed, consider a central cause. Evaluate on the basis of a careful history and physical examination and liberal use of imaging studies of the posterior fossa.
- Therapy usually targets the etiology of the symptoms. However, a variety of medications may be used to reduce symptoms of central vertigo, including antihistamines and benzodiazepines.
- Regardless of the vertigo's etiology, attempt to alleviate the patient's suffering.
- Place intravenous lines to rehydrate patients.
- Allow patients to lie still in bed as desired.
- Administer parenteral medicines for symptomatic relief.
- If clinical and radiologic evaluation suggest an acute ischemic stroke, consider thrombolytic therapy after thorough evaluation and consultation.
- Thrombolytic therapy is administered with an intra-arterial catheter close to the clot14 , or intravenously, if within 3 hours of the onset of symptoms and no other contraindications exist.15
- Prior to using thrombolytic therapy, consider several issues, especially the risk of intracerebral bleeding. Emergency physicians should be familiar with contraindications such as major surgery within the previous 10 days, severe hypertension, evidence of acute bleed or edema on CT scan, and rapidly improving symptoms.
- The decision to administer thrombolytic therapy preferably is made with direct neurologic consultation and only after the patient has received a thorough explanation of the procedure and given informed consent. This therapy is discussed further in other articles (see Stroke, Ischemic and Thrombolytic Therapy).
- Lethargic patients or those with altered level of consciousness require vigilance and close supervision, including direct visual, ECG, and pulse oximetry monitoring.
- Do not administer anticoagulant medicine, including aspirin, until intracranial hemorrhage has been ruled out by imaging.
- Imaging studies should be performed expeditiously, and the patient never should be left unattended by clinical personnel in the imaging suite.
- Patients with altered consciousness and a deteriorating course in the ED may require emergent interventions to minimize edema and brainstem compression.
- As the posterior fossa is a relatively small and nonexpandable space, hemorrhage or edema can lead to rapid compression and compromise of vital medullary functions, obstructive hydrocephalus, or herniation of the medullary tonsils.
- Invasive actions may include endotracheal intubation to protect the airway, control breathing, and allow therapeutic hyperventilation.
- Consider elevating the head of the bed, performing diuresis with mannitol or furosemide, and administering dexamethasone.
- Preliminary evidence suggests that recombinant activated factor VII may be useful for acute hemorrhagic stroke when administered within 4 hours of symptom onset.16 The data supporting the use of this therapy for hemorrhagic cerebellar stroke is too limited thus far to make a therapeutic recommendation, but further results are expected to clarify its utility and adverse effect profile.
Consultations
Obtain neurologic consultation for patients with central vertigo, and consider neurosurgical consultation for all patients with space-occupying lesions or hydrocephalus.
The emergency physician should seek immediate neurosurgical consultation for patients with hemorrhage, brainstem compression, or edema, as surgical decompression via suboccipital craniectomy or ventriculostomy may be lifesaving.
Medication
Patients with depressed mental status may have documented or suspected increased intracranial pressure (ICP). Administer diuretics or corticosteroids to decrease pressure while planning more definitive actions. Administer this therapy preferably in consultation with a neurosurgeon.
H1- receptor antagonists
These agents may suppress vestibular responses through an effect in the CNS; however, the mechanism remains unknown. Some investigators believe this action is mediated primarily by central anticholinergic activity.
Dimenhydrinate (Dramamine, Dimetabs, Dymenate, Triptone)
A 1:1 salt of 8-chlorotheophylline and diphenhydramine, thought to be particularly useful in treatment of peripheral vertigo. Diminishes vestibular stimulation and depresses labyrinthine function through central anticholinergic activity.
Adult
50-100 mg PO q4-6h; not to exceed 400 mg/d; 50 mg IV in 10 mL NaCl; injection is given over 2 min; not for intra-arterial administration; 50 mg IM prn
Pediatric
<2 years: Not established
2-6 years: 12.5-25 mg PO q6-8h, not to exceed 75 mg/d; 1.25 mg/kg or 37.5 mg/m2 IM qid, not to exceed 300 mg/d
6-12 years: 25-50 mg PO q6-8h; not to exceed 150 mg/d
>12 years: Administer as in adults
Alcohol or other CNS depressants may have additive effect; potentially ototoxic antibiotics may mask ototoxic symptoms, and irreversible damage may result
Documented hypersensitivity; do not administer to neonates; IV products may contain benzyl alcohol, which has been associated with fatal "gasping syndrome" in premature infants and low-birth-weight infants
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Do not treat severe emesis with antiemetic drugs alone; may contain either sulfites or tartrazine, which may cause allergic-type reactions in susceptible persons; may impede diagnosis of conditions such as brain tumors, intestinal obstruction, and appendicitis; may obscure signs of toxicity from overdosage of other drugs
Diphenhydramine (Benadryl, Bydramine, Hyrexin)
Used for treatment and prophylaxis of vestibular disorders.
Adult
25-50 mg PO q6-8h prn; not to exceed 400 mg/d; 10-50 mg IV/IM q6-8h prn; not to exceed 400 mg/d
Pediatric
12.5-25 mg PO tid/qid or 5 mg/kg/d PO or 150 mg/m2/d PO divided tid/qid; not to exceed 300 mg/d
5 mg/kg/d IV/IM or 150 mg/m2/d IV/IM divided qid; not to exceed 300 mg/d
Potentiates effect of CNS depressants; because of alcohol content, do not give syrup dosage form to patient taking medications that can cause disulfiramlike reactions
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
May exacerbate angle-closure glaucoma, hyperthyroidism, peptic ulcer, and urinary tract obstruction
Promethazine hydrochloride (Phenergan)
Used for symptomatic treatment of nausea in vestibular dysfunction.
An antidopaminergic agent effective in treatment of vertigo, blocks postsynaptic mesolimbic dopaminergic receptors in brain and reduces stimuli to brainstem reticular system.
Adult
12.5 mg PO/PR tid and 25 mg PO/PR hs; 25 mg IV/IM and repeat prn in 2 h; switch to PO as soon as possible
Pediatric
<2 years: Contraindicated
>2 years: 0.25-1 mg/kg PO/IV/IM/PR 4-6 times/d
May have additive effects with other CNS depressants or anticonvulsants; coadministration with epinephrine may cause hypotension
Documented hypersensitivity; administration by SC or IP route; children <2 y (incidences of death due to respiratory depression)
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Must not administer SC or IP, since necrotic lesions may develop; causes sedation and may have adverse anticholinergic effects; caution in cardiovascular disease, impaired liver function, seizures, sleep apnea, and asthma
Benzodiazepines
Centrally, these agents inhibit vestibular responses, presumably by potentiating inhibitory GABA receptors.
Diazepam (Valium, Diastat, Diazemuls)
Probably most commonly used benzodiazepine to treat vertigo. Highly lipophilic and undergoes rapid redistribution after administration. Duration of effects in CNS relatively short, which may make it relatively less desirable.
Adult
5-10 mg PO/IV/IM q3-4h and repeat q2-4h prn; not to exceed 30 mg/8 h
Pediatric
0.12-0.8 mg/kg/d PO divided q6-8h; not to exceed 10 mg/dose
0.05-0.3 mg/kg/dose IV/IM over 2-3 min and repeat in 2-4 h prn
Phenothiazines, barbiturates, alcohols, and MAOIs may increase toxicity in CNS
Documented hypersensitivity; narrow-angle glaucoma
Pregnancy
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Caution with other CNS depressants, low albumin levels, or hepatic disease (may increase toxicity)
Lorazepam (Ativan)
Sedative hypnotic in benzodiazepine class that has short time to onset and relatively long half-life.
Depresses all levels of CNS, including limbic and reticular formation, probably through increased action of GABA, a major inhibitory neurotransmitter.
Adult
1.0-10 mg/d PO/IM/IV divided bid/tid
Pediatric
0.05 mg/kg/dose PO/IM/IV q4-8h
Alcohol, phenothiazines, barbiturates, and MAOIs may increase toxicity in CNS
Documented hypersensitivity; preexisting CNS depression; hypotension; narrow-angle glaucoma
Pregnancy
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Caution in renal or hepatic impairment, myasthenia gravis, organic brain syndrome, or Parkinson disease
Diuretics
Diuretic agents are used as a temporary measure to lower ICP until definitive intervention is performed.
Mannitol (Osmitrol)
Nonreabsorbable solute, decreases water reabsorption in water-soluble portions of nephron. Reduces reabsorption of sodium chloride as well. Perhaps more importantly, does not cross blood-brain barrier. Creates osmotic gradient, drawing water from brain into intravascular compartment. Used to lower ICP in variety of conditions.
Initially assess for adequate renal function in adults by administering test dose of 200 mg/kg IV over 3-5 min. Should produce a urine flow of at least 30-50 mL/h over 2-3 h.
In children, assess by administering same test dose and rate. Should produce a urine flow of at least 1 mL/kg/h over 1-3 h.
Adult
1 g/kg IV of 20% or 25% solution
Pediatric
250-1000 mg/kg/dose IV or alternative as follows
Initial dose: 0.5-1 g/kg IV
Maintenance dose: 0.25–0.5 g/kg IV q4-6h
None reported
Caution in renal or hepatic impairment, myasthenia gravis, organic brain syndrome, or Parkinson disease
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Carefully evaluate cardiovascular status before rapid administration of mannitol, since sudden increase in extracellular fluid may lead to fulminating CHF; avoid pseudoagglutination—when blood given simultaneously, add at least 20 mEq of sodium chloride to each liter of mannitol solution; do not give electrolyte-free mannitol solutions with blood
Furosemide (Lasix)
Loop diuretic that blocks transport of sodium, potassium, and chloride in thick ascending limb of loop of Henle in kidney. May enhance effect of mannitol and produce greater and more sustained decrease in ICP.
Adult
20-40 mg/d IV/IM or 0.5-1 mg/kg IV
Pediatric
1 mg/kg IV/IM slowly under close supervision; not to exceed 6 mg/kg
Metformin decreases concentrations; interferes with hypoglycemic effect of antidiabetic agents and antagonizes muscle-relaxing effect of tubocurarine; coadministration of aminoglycosides may increase auditory toxicity (hearing loss of varying degrees may occur); may enhance anticoagulant activity of warfarin; increased plasma levels and toxicity of lithium are possible
Documented hypersensitivity; hepatic coma; anuria; severe electrolyte depletion
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Volume depletion, hypotension, azotemia, marked hypokalemia, and hypochloremic metabolic alkalosis are all risks of therapy; patient's intravascular volume status and serum electrolytes must be monitored closely; hypocalcemia also possible, particularly in patients with hypoparathyroidism
Transient deafness has been described after rapid IV administration of large doses, particularly when other ototoxic drugs also administered
Perform frequent determinations of serum electrolytes, CO2, glucose, creatinine, uric acid, calcium, and BUN during first few months of therapy and periodically thereafter
Corticosteroids
These agents are used to decrease brain edema associated with intracranial tumors.
Dexamethasone (Decadron)
Preferred corticosteroid for this purpose because it demonstrates high glucocorticoid potency and minimal mineralocorticoid activity.
Adult
10 mg IV followed by 4-6 mg IV q6h
Pediatric
0.5-1.5 mg/kg IV; then 0.05-0.1 mg/kg IV q6h
Barbiturates, estrogen, isoniazid, ketoconazole, phenytoin, and rifampin may decrease effects; decreases effect of salicylates and vaccines used for immunization
Documented hypersensitivity; active bacterial or fungal infection
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Increases risk of multiple complications, including severe infections; monitor adrenal insufficiency when tapering drug; abrupt discontinuation of glucocorticoids may cause adrenal crisis; hyperglycemia, edema, osteonecrosis, myopathy, peptic ulcer disease, hypokalemia, osteoporosis, euphoria, psychosis, myasthenia gravis, growth suppression, and infections are possible complications
More on Central Vertigo |
| Overview: Central Vertigo |
| Differential Diagnoses & Workup: Central Vertigo |
 Treatment & Medication: Central Vertigo |
| Follow-up: Central Vertigo |
| Multimedia: Central Vertigo |
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Further Reading
Keywords
central vertigo, vertigo, central vertigo causes, central vertigo treatment, central vertigo symptoms, acoustic neuroma, acoustic neurinoma, CNS tumor, CNS infection, peripheral ischemic vertigo, temporary vertebrobasilar ischemia, migraine syndrome, transient ischemic attacks, cerebellar infarction
