Dizziness

1. In patients complaining of dizziness, rule out serious cardiovascular, cerebrovascular, and other neurologic disease (e.g., arrhythmia, myocardial infarction [MI], stroke, multiple sclerosis).

2. In patients complaining of dizziness, take a careful history to distinguish vertigo, presyncope, and syncope.

3. In patients complaining of dizziness, measure postural vital signs.

4. Examine patients with dizziness closely for neurologic signs.

5. In hypotensive dizzy patients, exclude serious conditions (e.g., MI, abdominal aortic aneurysm, sepsis, gastrointestinal bleeding) as the cause.

6. In patients with chronic dizziness, who present with a change in baseline symptoms, reassess to rule out serious causes.

7. In a dizzy patient, review medications (including prescription and over-the-counter medications) for possible reversible causes of the dizziness.

8. Investigate further those patients complaining of dizziness who have:

   • signs or symptoms of central vertigo.

   • a history of trauma.

   • signs, symptoms, or other reasons (e.g., anticoagulation) to suspect a possible serious underlying cause. 

General Overview

• Differentiate Vertigo vs. Non-vertigo

  • Vertigo: Sustained (r/o stroke) vs. Episodic

  • Non-vertigo: 

    • Syncope (r/o CVS, seizure, hypoglycemia)

    • Pre-syncope (r/o CVS)

    • Disequilibrium (r/o neuromuscular)

    • Lightheadedness

• History

  • Time course - Vertigo cannot be continuous for >few weeks (CNS adapts), likely psychogenic

    • Acute prolonged severe vertigo (Stroke, demyelinating disease, vestibular neuronitis)

    • Recurrent spontaneous attacks, minutes-hours (Meniere, Vestibular Migraine)

    • Recurrent positional, seconds-minutes (BPPV)

    • Chronic persistent dizziness (Psychogenic, cerebellar ataxia)

  • Provoking factors

    • Head position (Positional vertigo) vs. postural presyncope

  • Review medications

  • Prior history of migraine

  • Stroke risk factors

  • Deafness/tinnitus/ear pain often in peripheral

r/o Central Vertigo

• Red flags: 

  • Diplopia, Dysarthria, Dysphonia, Dysphagia, Dysmetria

  • Multiple transient prodromal episodes of dizziness over weeks/months

  • Headache, neck pain, recent trauma (vertebral artery dissection/aneurysm)

  • Auditory symptoms (despite mimicking benign peripheral causes, hearing loss in acute vestibular syndrome is frequently associated with stroke)

  • Neuro signs: Facial palsy, sensory loss, limb ataxia, hemiparesis, oculomotor (Internuclear ophthalmoplegia, gaze palsy, vertical nystagmus)

  • Gait unsteadiness

Physical Exam

• Vital signs, orthostatic

• Ears: TM x2

• Eyes: 

  • Nystagmus

    • • • Peripheral: Unidirectional, Horizontal nystagmus, Suppressible with visual fixation, Positional

        • Central: Uni or Bi-directional, Purely vertical/horizontal/torsional nystagmus, Not suppressible, Not positional (ie. Central is usually Spontaneous)

• Neuro

  • CN

  • Cerebellar: Romberg (vestibular dysfunction on ipsilateral)

  • Gait (including Tandem to observe truncal ataxia suggestive of cerebellar dysfunction)

• • • Central causes often severe instability

• • Motor/Sensory (weakness, paresthesia)

Episodic Vertigo

• If BRIEF episodes related to head movement, AND absent spontaneous/gaze-evoked nystagmus, may consider BPPV

  • • Dix-Hallpike (Posterior semicircular canal)

      • Positive if torsional (rotatory) nystagmus + vertigo (Diseased ear downmost)

        • Typical

          • Latency (delay up to 20s before nystagmus)

          • Fatigueability (Nystagmus fades)

          • Habituation (Repeating test produces less response)

    • Alternative in seated position: Bow & Rise Test (turn head 45 degrees, bow to move head to horizontal and quickly return to vertical)

    • Consider Supine RollTest (Horizontal Canal BPPV)

• Longer episodes (minutes to hours)

• • Migrainous = Headache

  • Meniere's = Unilateral ear fullness, tinnitus, fluctuating hearing loss, severe vertigo

  • Vertebrobasilar TIA = Neurological deficits 

 Acute Vestibular Syndrome

• Acute onset, sustained vertigo

  • Must differentiate between stroke vs. acute idiopathic unilateral peripheral vestibulopathy (vestibular neuritis, labyrinthitis)

  • Almost 2/3 of patients with stroke lack focal neurological signs, thus use HINTS or Sudbury Vertigo Risk Score to rule out stroke.

    • HINTS+ only in Acute Vestibular Syndrome (to differentiate stroke from vestibular neuritis) in patients with current nystagmus (If no nystagmus, will need to rely on detailed neurological exam (CN, hearing, anisocoria, phonation, facial sensation, cerebellar ataxia, gait)

      • Head Impulse - Rapid head rotation towards mid-line with eyes fixed on object (normal suggests central cause)

      • Nystagmus - Vertical/bidirectional/torsional (note torsional is expected in episodic BPPV, but not in acute vestibular syndrome due to peripheral cause)

      • Test of Skew - Skew deviation or misalignment on cover-uncover test

      • Presence of one INFARCT (impulse normal or fast-phase alternating or refixation on cover test) may be more accurate to diagnose stroke than urgent MRI

        • Negative INFARCT (abnormal head impulse, horizontal unidirectional nystagmus, no skew deviation), but may not be enough to rule out stroke in the emergency room

      • + Hearing loss, rule-out AICA infarct

Investigations

• EKG (r/o Arrhythmia, MI)

• CBC, Lytes, TSH (Low yield)

• MRI (83% sensitive), CT (16% sensitive)

  • MRI can miss stroke (20% false negative) until 48h after symptoms

Treatment Summary

• General acute symptomatic management of vertigo: Antihistamines, Benzodiazepines, Antiemetics

• Peripheral (early ENT referral as needed, and vestibular rehab)

  • BPPV (episodic seconds, head position)

    • Epley maneuver

    • Sermont maneuver

    • Gufoni maneuver in horizontal canal BPPV

    • Betahistine 24mg PO BID limited evidence

  • Meniere's (episodic minutes-hours, hearing loss, tinnitus/ear fullness)

    • Limit salt, caffeine, nicotine, alcohol

    • Betahistine, Diuretic

  • Vestibular neuritis and Labyrinthitis (single acute onset, lasts days, possible viral syndrome)

    • Methylprednisone 22-day tapering dose schedule

    • Supportive

• Central

  • Vestibular migraine (episodic minutes-hours with migraine headache)

  • Brainstem or cerebellar infarct (persistent over days-weeks, vascular risk factors, prominent gait impairment) or TIA  (episodic minutes-hours, vascular risk factors) 

    • MRI

    • Evaluation for Thrombolysis/Thrombectomy 

    • Secondary risk management

      • Antihypertensives if BP >140/90

      • Aspirin or clopidogrel

      • Atorvastatin 80mg/day (SPARCL trial)

      • Carotid endarterectomy for recent symptom

      • Holter-24-48h r/o Afib

      • Echocardiography

      • Lifestyle

        • Glucose control if diabetic

        • Eliminate alcohol, smoking

        • Exercise

• Referral

  • ENT, Neurology, Psychiatry

  • Vestibular rehab

  • PT/OT