Dizziness – AAFP 2010

Non-vertiginous dizziness:

Syncope
  • Sudden transient LOC due to global cerebral HoTN
  • Cardiac arrhythmias, AS, vasovagal, orthostatic HoTN, hyperventilation, metabolic causes (HoTN, med S/E, caffeine, nicotine)
  • High mortality / Morbidity: CVA, AS, arrhythmias, high ICP
  • If CPR or cardioversion required, then SCD and NOT syncope
Pre-Syncope
  • Prodromal symptoms of fainting, nearly fainted / blacked out
  • lightheadedness, sweating, panic, anxious, difficulty maintaining posture
Disequilibrium
  • Sense of imbalance, occurs when walking, unsteady on feet; not present lying or sitting
  • eg. peripheral neuropathy, cerebellum or posterior column dz, Parkinson dz
Psychogenic dizziness
  • Constant complaints, difficult to describe, localize, underlying psychiatric dz likely
  • Depression, anxiety, panic disorders, phboic dizziness

Vertigo: Two types
  • Illusion of rotational, linear, or tilting movement of self or environment
  • Produced by peripheral (inner ear) or central (brainstem-cerebellum) stimulation
  • The result of a mismatch between the 3 sensory systems: the vestibular, visual, and somatosensory systems
1) Central Vertigo
  • Mild-mod imbalance, variable N/V, rare auditory symptoms, common neurologic symptoms, slow compensation, bidrectional nystagmus (horizontal or vertical)
2) Peripheral Vertigo
  • Mod-Severe imbalance, severe N/V, common auditory symptoms, rare neurologic symptoms, rapid compensation (wk), unidirectional nystagmus (horizontal or rotatory)

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

  • Presyncope / Syncope: arrhythmia, MI, stroke, carotid artery stenosis, orthostatic HoTN, AAA, sepsis, carotid sinus hypersensitivity, orthostatic HoTN, vasovagal, situational
    • HPI:
      • Symptoms with change in position / exertion (postural HoTN)
      • Palpitations, chest pain
      • a-blocker, b-blocker, diuretic, nitrates, Viagra, opioids, antipsychotics, TCA, Parkinson’s meds
      • syncope immediately follows cough, sneeze, defecation, micturition (situational)
      • Syncope associated with head turning, tight shirt collars (carotid hypersensitivity)
      • Prodromes: sweaty, lightheaded, tinnitus, palor, slow onset, nausea, blurry vision (vasovagal)
    • PEx:
      • Orthostatic VS, check pulses for arrhythmia
      • Carotid bruit, carotid sinus massage (carotid hypersensitivity)
      • Tilt-table (vaso-vagal)
    • Ix:
      • ECG, Holter
      • Carotid doppler
    • Tx:
      • Orthotstaic HoTN – Lifestyle and a-agonists – Midodrine 10mg po tid; Mineralocorticoid: Fludrocortisone 0.1mg po daily 
  • Disequilibrium: Parkinson’s, peripheral neuropathy, MS, other MSK weakness; stroke (generally with other neurologic symptoms)
    • HPI: r/o stroke / TIA – unilateral weakness, garbled speech
    • PEx: Gait
  • Vertigo: BPPV, Meniere’s, Labyrinthitis, migraine
    • HPI: hearing loss, tinnitus
      • Migraine / photophobia / phonophobia / aura
    • PEx:
      • Dix-Hall pike maneuver – head at 45o and lay back causing nystagmus
      • Webber & Rinne (air > bone & hearing loss – sensory neural problem)
    • Ix:
      • hearing test, investigate further if central vertigo
    • Tx:
      • BPPV – Epley or Meclizine (Antivert) 25-50mg po Q4-6h, vestibular rehabilitation
      • Meniere Dz – salt restriction, avoid cofee / EtOH, SERC+ diuretics (HCZ) or intratympanic dexamethasone or gentamicin (ENT)
      • Vestibular neuritis – Methylprednisolone (DepoMedrol) 100mg po daily and taper to 10mg over 3 weeks
      • Migrainous vertigo – Prophylaxis with anticonvulsant, TCA, propanolol, Candasartan
  • Light-headedness with hyperventilation – r/o anxiety / panic attacks
    • Tx: breathing control exercise, B-blockers antianxity agents

DDx of Dizziness

1) Vertigo:
Nystagmus & vertigo
  • BPPV
    • Normal hearing, episodic
  • Labyrinthitis
    • + hearing loss, persistent vertigo
  • Vestibular neuronitis
    • normal hearing, persistent vertigo
  • Meniere’s dz – increased endolymphatic fluid
    • episodic vertigo with + hearing loss / tinnitus
  • Recurrent vestibulopathy, Perilymph Fistula
  • Temporal bone #, superior semicircular canal dehiscence
  • Ototoxic drug exposure
  • Autoimmune inner ear dz, Cholesteatoma
Central
  • Cerebrovascular disorders
    • Vertebrobasiliar insufficiency: 5D’s-
      • Drop attacks, Dysarthria, DiplopiaDizziness, Dysphagia (features r/o peripheral vertigo)
    • TIA, Wallenberg’s syndrome
    • Cerebellar infarction
  • Migrainous vertigo / vestibular migraine
    • episodic vertigo with signs of migraine
  • MS – see MS post
  • Tumours: CPA tumours, Posterior fossa tumours, Glomus tumours
  • Inflammation: Meningitis, Cerebellar abcess
  • Trauma: cerebellar contusion
  • Toxic: alcohol, hypnotics, drug
2) Non-Vertiginous – Organic dz
  • Cardiac: AS, Arrhythmias
  • Vasovagal (Neurocardiogenic)
  • Orthostatic HoTN (30-20-10 rule)
    • commonly due to meds
    • Tx: alpha agonists, mineralcorticoids, lifestyle changes
  • Anemia
  • Peripheral Neuropathy – disequilibrium – decreased tactile response when walking
  • Visual Impairment
  • Parkinson dz – disequilibrium – dysfunction in gait causing imbalance and falls
    • shuffling gait with reduced arm swing
Functional
  • Depression, anxiety, panic disorder (hyperventilation), Personality disorder
  • Phobic dizziness
Condition Duration Hearing loss Tinnitus Aural fullness Other features
BPPV Seconds
Meniere’s dz Min to hr precedes attack Uni/bilateral, fluctuating + Pressure / warmth
Vestibular Neuronitis Hours to days
Labyrinthitis Days Unilateral Whistling Recent AOM
Acoustic neuroma Chronic Progressive + Ataxia, CNVII palsy

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

Hx:
  • Describe the sensation – distinguish vertigo, presyncope, and syncope
    • Vertigo – false sense of motion, possibly spinning sensation
    • Disequilibrium – off-balance or wobbly
    • Presyncope – feeling of blacking out, associated palpitations / SOB
    • Lightheadedness – vague symptoms, possibly feeling disconnected with the environment
  • Onset, palliative when sitting, severity, timing, direction of spinning
  • Associated otologic symptoms: tinnitus / aural fullness / hearing loss, occur with vertigo episode or permanent
    • Recent URTI, OM, trauma, N/V
    • Travel, sick contacts, rashes, tick bites
  • Associated neurological symptoms: dysarthria / dysphagia, LOC, H/A,ataxis, falls
    • Is there difficulty walking? Is the speech slurred?
    • Are there visual disturbances: diplopia, poor vision, etc?
    • Any CNS symptoms (assume central vertigo)?
  • Changes in vision, hearing eyes moving (canal dehiscence)
Red flags:
  • syncope, angina, focal neurologic deficits, H/A, diplopia

vertigo


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

Orthostatic VS have the highest yield and is the most cost effective PEx for syncope


4  Examine patients with dizziness closely for neurologic signs.

PEx
  • General: ABC / VS, orthostatic VS, GCS
  • Neuro-otologica exam (vertigo)
    • General appearance
    • Ears – canal and TM, Webber & Renne (conductive vs sensorineural hearing loss)
    • Nose – signs of URTI
    • Oral cavity / oralpharynx – signs of pharyngitis
    • Neck – masses / LN
    • CN: 2-12 – smooth pursuit (CN 3,4,6) – saccadic eye movements associated with central cause, eg brainstem or cerebellar dz
    • Vestibulo-ocular reflex
    • Head shaking (pt lean forward 30 degrees while MD shakes head back and forth x 20sec) nystagmus = peripheral cause
    • Cerebellar exam:
      • Romberg – swaying toward one side indicative of vestibular dysfunction
      • Gait – slow, wide-based, irregular – indicative of cerebellar dysfunction
      • tandem gait, finger-to-nose, heal-shin, dysdiadochokinesis, dysmetria
    • Screening for peripheral neuropathy
    • Fundoscopy to look for hich ICP
    • Dix-Hallpike – dx for BPPV
  • Cardiovascular exam – carotid bruits, systolic murmur (AS)
    • Ask pt rapidly take 20 deep breaths – attempt to reproduce symptoms of hyperventilation syndrome
    • ECG, holter, carotid doppler

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


Ix: generally low yeild
  • B/W: CBC, electrolytes, Cr, urea, Troponin, TSH
  • Radiology: CXR, carotid doppler, CT (labrynthitis), CT head (central vertigo), MRI (acoustic neuroma), MRA head (brain lesions, infections, CVA)
  • Speical tests
    • ECG, 24hr Holter monitor (arrhythmias)
    • BNP (CHF)
    • EEG (Sz)
    • Pure-tone audiometry, audiogram
    • VNG – calorics, ENG, posturography

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.

A medication history should be obtained because dizziness (especially from orthostatic hypotension) is a well-known adverse effect of many drugs

  • Cardiac Medications
    • Alpha blockers – terazosin
    • a/b blockers – labetalol
    • ACEi, b-blockers
    • Clonidine, dipyridamole (persantine), hydralazine, methyldopa
    • Diuretics: furosemide
    • Nitrates: nitroglycerin
  • CNS medications
    • Antipsychotics: clozapine
    • EtOH, caffeine
    • Opioids
    • Parkinsonian drugs – bromocriptine, levodopa/carbidopa
    • Skeletal muscle relaxants: baclofen, cyclobenzaprine
    • TCA: amitriptyline, trazodone
  • Urologic medications
    • Phosphodiesterase 5 inhibitors: sildenafil
    • Urinary anti-cholinergics: oxybutynin

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.

Central Vertigo
  • Mild-moderate imbalance
  • Variable N/V
  • Rare auditory symptoms
  • Common neurologic symptoms: dysarthria, diplopia, facial droop, dysphagia, limb dysmetria, gait impairment
  • slow compensation
  • Bidirectional nystagmus – horizontal or vertical

Consult neurologist with central vertigo or peripheral vertigo > 2 weeks

Order CT / MRI of head –
  • Vertebrobasilar TIA: older pt, vascular risk factors, cervical trauma
  • Brainstem infarct: sudden onset, persistent over days to weeks, usually other brainstem symptoms (lateral medullary signs)
  • Cerebellar infarction / hemorrhage: sudden onset, persistent symptoms, vacular risk factors (HTN), Gait impairement, H/A, limb dysmetria, dysphagia
  • Migrainous vertigo : normal imaing tests

References:
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Posted in 29 Dizziness, 99 Priority Topics, FM 99 priority topics, Neuro

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