1.Differentiation: true vertigo and pseudovertigo
(1) True vertigo is caused by diseases of the eye, proprioception or vestibular system, with obvious sensation of external objects or self rotation. It can be divided into ophthalmic, proprioceptive disorders and vestibular vertigo depending on the site of damage.
(2) Pseudovertigo It refers to vertigo caused by systemic diseases (not caused by vestibular system), such as cardiovascular disease, cerebrovascular disease, anemia, uremia, drug intoxication, endocrine disease and neurosis, etc. Almost all of them have symptoms of dizziness of varying severity.
2.Distinguish: periventricular and central vestibular vertigo
(1) Periventricular vestibular vertigo (80%): caused by inner ear and auditory nerve.
(2) Central vestibular vertigo (20%): caused by lesions of vestibular nucleus, cerebellum and brain.
(3) Vestibular circumferential vertigo
Inner ear.
(1) Benign paroxysmal positional vertigo BPPV.
(2)Meniere’s syndrome
Auditory nerve.
(1)Vestibular neuronitis
(2)Tumor
4. Central vestibular vertigo
Brainstem: vascular (vertebrobasilar artery), tumor, inflammation, malformation, degeneration
Brain: vascular, tumor, inflammation
Cerebellum: vascular, tumor, inflammation
5.Pseudovertigo
(1)Eye, cardiovascular, infection, poisoning, metabolism
(2)Cranial trauma, migraine, epilepsy, neurosis
(3)Cervical spine
6.Treatment of vertigo
Principle: Etiological treatment is fundamental.
I. Treatment in the acute stage.
1.General treatment.
(1) Pay attention to prevent falls and bruises;
(2) Quiet rest, choose the most comfortable position, avoid sound and light stimulation;
(3), low salt and low fat diet;
(4).Low flow oxygen intake;
(5) Control the intake of water and salt to reduce the edema of the inner ear vagus and vestibular nucleus.
2.Symptomatic treatment.
(1).Anti-vertigo: optional anti-dizziness drugs such as min make lang (merislon) 6mg, vertigo stop 25~50mg3/day, or cipro 5mg1/night; in severe cases, tranquilizers such as valium (10mg) or non-nagen (25~50mg), luminal (0.1g) intramuscular injection can also be added, but attention should be paid to drug dose and blood pressure drop.
(2), anti-vomiting: after the application of the above sedatives, the patient can fall asleep for several hours immediately, and the symptoms can be relieved after waking up, but it is advisable to repeat the drug 1 to 2 times to consolidate the effect. Need to fashion can be used morpholine 10mg3/day or gastric renformation 10mg intramuscular injection or oral 3/day.
(3), other: for those who have anxiety, depression symptoms first psychotherapy, when needed, can use Prozac (20m), Zoloft (50mg) and other anti-anxiety antidepressants. Pay attention to the prevention and control of water-electrolyte and acid-base balance for those who have little food and heavy vomiting, and rehydrate intravenously if necessary.
II. Intermittent treatment
1.Prevent relapse: avoid excitement, mental stimulation, overeating, water and salt overdose, and avoid smoking and alcohol to enhance resistance to relapse.
2.Strengthen the management of risk factors: regulate the stability of blood pressure, prevent the blood pressure from being too high or too low; avoid drastic changes of head position, etc.
3. Find and treat the cause of the disease: actively find the cause of the disease, and actively treat the cause of the disease, such as surgical resection of auditory nerve sheath tumor, manipulative reset of jugular crest stone disease and staging treatment of cerebrovascular disease. If the cause is clear but cannot be removed in one fashion, drug treatment can be given.
Commonly used drugs and their treatment mechanism
1.Sedatives
(1), Valium: mechanism: γ-amino acid T receptor inhibitor, can inhibit the activity of the vestibular nerve nucleus, and has anxiolytic and muscle relaxation effect. Dose: 5-10mg orally 1~2 times / day, vomiting severe can be changed to 10mg intramuscularly or quietly.
(2), lidocaine: mechanism: can reduce the neural excitability of brainstem and vestibular end-organ. Dose: 1~2mg/kg added to 5% glucose 100~200ml in static drip or slow push. It is effective in reducing vertigo and tinnitus, but attention should be paid to cardiac complications.
2. Anticholinergic agents: Mechanism: blocking the binding of acetylcholine and cholinergic receptors, relieving smooth muscle spasm, dilating blood vessels, improving inner ear microcirculation and inhibiting glandular secretion. It is suitable for people with severe gastrointestinal and other autonomic reactions, but is contraindicated in glaucoma.
(1) Hydrobromoscopolamine: parasympathetic blocker, 0.3-0.5mg orally, dermally or diluted in 5% glucose 10ml slowly by sedation.
(2), Scopolamine Transdermal Therapy System (TTS-S): good effect on Meniere’s disease vertigo, especially for those with severe nausea and vomiting.
(3), Atropine: 0.5mg subcutaneous injection or intramuscular injection.
(4).Scopolamine (654-2): 10mg intramuscularly or intravenously.
3. Agents with both sedative and anticholinergic effects: such as benadryl, fenagan, etc.
4.Improve blood circulation and anti-dizziness class.
(1), flunarizine hydrochloride: mechanism: selective Ca2+ channel blocker, can block Ca2+ transmembrane entry into cells under hypoxic conditions, causing cell death; inhibit vasoconstriction, reduce vascular resistance; reduce vascular permeability, reduce membrane vagal fluid accumulation, increase small arterial blood flow in the cochlea, improve inner ear microcirculation. Dose: 10mg (under 65 years old), 5mg (over 65 years old) orally 1/night, should be discontinued promptly after symptom control, the initial course of treatment often does not exceed 2 months. Chronic vertigo for 1 month or sudden vertigo for 2 months with poor efficacy should be discontinued.
(2), Minerva: The ingredient is betahistine mesylate, which is a histamine drug with longer lasting effect than histamine. Mechanism: It has strong vasodilator effect, improves microcirculation in brain, cerebellum, brainstem and inner ear, and increases blood flow in the brain. It can adjust the permeability of inner ear capillaries, promote the secretion and absorption of inner ear lymphatic fluid, and eliminate inner ear edema. It can inhibit the release of histamine and produce anti-allergic effect. It has better effect on inner ear vertigo. Dose: 6-12mg3/day; 10ml3/day of Ciclestin oral solution. In severe cases, Ciclestin injection (containing 20mg of betahistine) can be added to 250ml of glucose saline as an IV1/day, 10-15 times as a course of treatment.
(3), sodium bicarbonate: mechanism: neutralize acidic metabolites in the lesion area, release C02 and increase local C02 partial pressure, dilate capillaries, improve microcirculation; release medium and small artery spasm; improve the body’s alkali reserve and promote the normalization of nutritional processes. Dose: 3% NaHC03100~200ml IV 1/day for 5 times.
(4), poppy bases hydrochloride: mechanism: relax vascular smooth muscle, reduce cerebrovascular resistance. Dose: 30～60mg3/day subcutaneously, intramuscularly and intravenously, total dose should not exceed 300mg a day.
(5), 55% C02 mixed oxygen inhalation: Mechanism: affect the carbonic anhydrase in the vascular striae, absorb hydrogen ions into the cochlea, lower endolymphatic pH and improve inner ear microcirculation. Dose: 15 minutes per inhalation, 3/day.
(6), low molecular dextran: mechanism: reduce blood viscosity to prevent intravascular coagulation, adsorb and change the surface charge of red blood cells and platelets, prompting red blood cells to repel and not easily coagulate; increase plasma colloid osmotic pressure, increase blood volume and dilute blood effect; short residence time in the body, easy to excrete from urine, osmotic diuretic effect to improve the inner ear microcirculation. Dose: 250-500m1 static drip 1/day, 7-14 times continuously.
(7), Chinese medicinal preparations: compound salvia, Chuanxiongzin, thromboxane, ginkgo biloba preparations, geranoside, etc. have vasodilating effects.
5.Diuretics
(1), acetazolamide: mechanism: a carbonic anhydrase inhibitor, so that the glomerular H + and Na + exchange slowed down, water excretion increased, eliminate inner ear edema and reduce exolymphatic osmolality dose: 250mg oral 2 ~ 3 / day, the highest efficacy after breakfast, the effect can last 6 ~ 8 hours, the efficacy of the acute attack is better. Long-term users can also take oral potassium chloride extended-release tablets 0.5g3/day.
(2), Dihydrocotrimoxazole: Mechanism: Act directly on the ascending branch of the renal medullary loop and the distal tubule, inhibit the reabsorption of Na+, promote water and sodium excretion (diuresis), reduce inner ear edema and improve blood circulation. Dose: 25~50mg orally 2~3/day. The effect of the drug will appear in 1 hour after oral administration, and will reach the peak in 2 hours, and the effect will last for 12 hours. The dose should be stopped or reduced after 1 week of oral administration. Long-term administration may cause hypokalemia, so attention should be paid to potassium supplementation.
(3), 50% glycerol solution: increase the osmotic pressure of ectolymph and reduce the accumulation of water in the membrane vagus. 50-60ml orally 2/day.
6.Other drugs
(1), triphosphoadenosine: mechanism: can directly diastolic vascular smooth muscle, lower blood pressure; involved in body fat, protein, sugar nucleotide metabolism, supply energy for cells. Dose: 10-20mg intramuscular injection or add low molecular dextrose drip 1/day, 1~2 weeks as a course of treatment.
(2), cytidyl phosphorylcholine: mechanism: improve brain tissue metabolism. Dose: 0.25 intramuscular injection 1~2/day or 0.5~1.0 IV1/day.
(3), steroids: beneficial for Meniere’s disease related to autoimmune or allergic factors. Dose: dexamethasone tablets 0.75mg orally 3/day, decreasing after 1 week; or dexamethasone 5-10mg IV 1/day, decreasing after 3-5 days.
(4), vitamins: such as vitamin B, C and niacin, etc.