Vertigo is a difficult management problem in General Practice. Dr Benjamin Tsang will discuss this condition and help us to understand vertigo and what the patient may be dealing with. This is part two of this article. Read Part one>>

Practice points

• Our current teaching about transient ischaemic attacks (TIA) in textbooks does not recognise isolated vertigo as a symptom, but actually it can be.
• Young patients with stroke and presenting with isolated vertigo are seven-fold more likely to be misdiagnosed than elderly patients.
• Intracerebral haemorrhages rarely mimic benign vertigo presentations. Rapidly deteriorating, altered level of consciousness is typically an accompanying symptom of intracerebellar haemorrhage due to increasing mass effect by expanding intracerebral haematoma.
• An acute headache can be red flag if accompanied by acute vertigo. To diagnose vestibular migraine there should be a pre-existing diagnosis of a migraine disorder, e.g. migraine with aura. Vertebral artery dissection can mimic migraine very closely, but differs in that with vertebral artery dissection there is acute headache and neck pain, together with acute vertigo, with or without other lateralising neurological symptoms.
• The combination of acute vestibular loss with acute hearing loss is a red flag, because it could be an anterior inferior cerebellar artery stroke.
• Focal neurological signs have been shown to be uncommon in posterior circulation stroke patients presenting with acute isolated vertigo, and therefore the motor examination focusing on the limbs may not be very useful. Look carefully for spontaneous nystagmus and eye movement abnormalities that suggest central, rather than peripheral oculomotor signs. A comprehensive oculomotor assessment (e.g. the HINTS plus examination battery) has more yield than the peripheral neurological examination.