A practical approach to dizziness Michael Gilchrist, MD MPH 8/17/09

Case 71 year old female with hypertension present to clinic with “dizziness”. What questions would you ask?

Dizziness Common primary care complaint Vertigo, presyncope, disequilibrium, other

Outline Presyncope Vertigo History and physical Warning signs Causes Characteristics of different causes History and physical Warning signs How to approach the patient?

“I’m dizzy” Non-specific term Vertigo and psychiatric causes make up the majority of cases seen in clinic setting (55-70%) Multicausal, presyncope, unknown, hyperventilation

Presyncope Prodromal symptom of fainting Usually occurs when patient is standing or upright, not supine Orthostatic hypotension, cardiac arrhythmias, vasovagal attacks most common

Other causes Parkinson’s disease Peripheral neuropathy Hyperventilation Medications Hypoglycemia Psychiatric disorders

Vertigo vs. presyncope Positional vertigo and postural presyncope often confused Both can occur when someone goes from sitting to standing Vertigo (especially BPPV) can be provoked with maneuvers that move the head without changing BP

Vertigo Dysfunction of vestibular system (central vs. peripheral)

Vertigo Illusion of motion Self-motion Motion of the surrouding environment “spinning”, “tilting”, “moving” All vertigo is made worse by moving the head.

The history… Patient description (“spinning” sensation, however is non-specific) Time course Vertigo is rarely described as continuous. Hearing loss? If so, duration and progression, unilateral vs. bilateral, tinnitus, sx of otitis

Causes of Vertigo Peripheral Central Migrainous vertigo Brainstem Benign positional vertigo Vestibular neuritis Herpes zoster oticus Meniere’s disease Labyrinthine concussion Cogan’s syndrome Acoustic neuroma Aminoglycoside toxicity Otitis media Central Migrainous vertigo Brainstem TIA Wallenberg’s syndrome Cerebellar infarcation or hemorrhage Chiari malformation MS

BPV Most commonly recognized form of vertigo Attributed to calcium debris within the semicircular canal (canalithiasis) “I feel like the room is spinning when I turn my head” Lasts seconds, but pt may feel destabilized for hours after an attack No ear pain, tinnitus, or hearing loss

BPV (cont.) Diagnosis usually made by history Dix Hallpike maneuver Positive in 50-80% of patients Canalith repositioning maneuvers Medical therapy usually not helpful due to transient symptoms

Vestibular neuritis Viral or postviral inflammatory disorder Rapid onset of severe persistent vertigo with nausea, vomiting, ataxia Sometimes combined with unilateral hearing loss (labyrinthitis) Steroid taper. Dramamine, meclizine (H1 blockers), benzodiazapines

Herpes zoster oticus AKA Ramsay Hunt syndrome Activation of latent herpes zoster infection Vertigo + hearing loss, ipsilateral facial paralysis, ear pain, vesicles Antiviral therapy

Meniere’s disease Excess endolymphatic fluid pressure Episodic, acute vertigo, lasts minutes to hours Unilateral tinnitus, hearing loss, ear fullness Treatment Salt, caffeine, tobacco restriction Diuretics Surgical

Labryinthine concussion Traumatic vestibular injury following head trauma Transverse fractures of the temporal bone

Cogan’s syndrome Autoimmune Similar to Meniere’s: veritgo, ataxia, nausea, vomiting, tinnitus, hearing loss “oscillopsia”: perception of objects jiggling after abruptly turning the head

Acoustic neuroma Slow growing tumor Patients often experience mild vertigo or no vertiginous symptoms at all Unilateral tinnitus and hearing loss MRI brain

Otitis media Fever, hearing loss, nausea, vomiting If pt has pain with tragal stimulation, consider CT scan of face to evaluate for labryinthine fistula in the temporal bone

Peripheral causes Benign positional vertigo - most common, no hearing loss Vestibular neuritis - sometimes hearing loss Herpes zoster oticus (Ramsay-Hunt) Meniere’s disease - unilateral hearing loss Labyrinthine concussion Cogan’s syndrome - autoimmune Acoustic neuroma - often minimal vertigo Aminoglycoside toxicity Otitis media

Central causes…

Migrainous vertigo Can have central and peripheral manifestations Diagnosis made by history (aura, headache Sometimes associated with migraine headaches

Brainstem ischemia Vertebrobasilar arterial system Rarely the sole manifestion, however MRI brain

Wallenberg’s syndrome Lateral medullary infarction Posterior inferior cerebellar artery Oftentimes concurrent Ocular movements Ipsilateral Horner’s syndrome Ipsilateral limb ataxia Sensory loss Hoarseness, dyphagia (CN IX)

Cerebellar infarction/hemorrhage Sudden intense persistent vertigo with nausea and vomiting. Pronounced gait abnormalities Pt falls toward the side of the lesion Typically older pts (>60 y/o) with CV risk factors

Warning signs Suggestions of central vestibular disease or brainstem lesions Persistent vertigo Ataxia Nausea/vomiting Headache Vision loss, diplopia Slurred speech

Vertigo, physical exam findings Nystagmus Hallpike maneuver Move patient rapidly from sitting to lying position, head tilted downward of facing you

The Dix-Hallpike Test of a Patient with Benign Paroxysmal Positional Vertigo Affecting the Right Ear Figure 2. The Dix-Hallpike Test of a Patient with Benign Paroxysmal Positional Vertigo Affecting the Right Ear. In Panel A, the examiner stands at the patient's right side and rotates the patient's head 45 degrees to the right to align the right posterior semicircular canal with the sagittal plane of the body. In Panel B, the examiner moves the patient, whose eyes are open, from the seated to the supine right-ear-down position and then extends the patient's neck slightly so that the chin is pointed slightly upward. The latency, duration, and direction of nystagmus, if present, and the latency and duration of vertigo, if present, should be noted. The red arrows in the inset depict the direction of nystagmus in patients with typical benign paroxysmal positional vertigo. The presumed location in the labyrinth of the free-floating debris thought to cause the disorder is also shown. Furman J and Cass S. N Engl J Med 1999;341:1590-1596

Central vs. Peripheral Vertigo Nystagmus unidirectional, horizontal with a torsional component Other neurologic signs absent Deafness or tinnitus may be present Central Nystagmus can be in any direction Other neurological signs often present Gait instability Deafness or tinnitus typically absent Often less severe More likely to be chronic, not episodic

High yield historical questions Subjective description, avoid leading questions Duration/frequency of symptoms Triggering factors Associated nausea/vomiting? Hearing loss or tinnitus? Any other neurological complaints Recent viral illness, fever, systemic symptoms? New medications?

Physical exam Neurological exam Check for nystagmus with and without Dix-Hallpike Ear exam Gait Cardiovascular exam