Dizziness
- In patients complaining of dizziness, rule out serious cardiovascular, cerebrovascular, and other neurologic disease (e.g., arrhythmia, myocardial infarction [MI], stroke, multiple sclerosis).
- In patients complaining of dizziness, take a careful history to distinguish vertigo, presyncope, and syncope.
- In patients complaining of dizziness, measure postural vital signs.
- Examine patients with dizziness closely for neurologic signs.
- In hypotensive dizzy patients, exclude serious conditions (e.g., MI, abdominal aortic aneurysm, sepsis, gastrointestinal bleeding) as the cause.
- In patients with chronic dizziness, who present with a change in baseline symptoms, reassess to rule out serious causes.
- In a dizzy patient, review medications (including prescription and over-the-counter medications) for possible reversible causes of the dizziness.
- 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
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
- Time course - Vertigo cannot be continuous for >few weeks (CNS adapts), likely psychogenic
r/o Central Vertigo
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
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)
- Nystagmus
- 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
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)
- Typical
- Positive if torsional (rotatory) nystagmus + vertigo (Diseased ear downmost)
- 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)
- Dix-Hallpike (Posterior semicircular canal)
- 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 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 to rule out stroke.
- HINTS+ only in Acute Vestibular Syndrome (to differentiate stroke from vestibular neuritis) in patients with current nystagmus
- 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
- If no nystagmus, will need to rely on detailed neurological exam (CN, hearing, anisocoria, phonation, facial sensation, cerebellar ataxia, gait)
Investigations
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
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
- BPPV (episodic seconds, head position)
- 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
References:
- CMAJ 2020. https://www.cmaj.ca/content/192/8/E182
- CMAJ 2011. http://www.cmaj.ca/content/183/9/E571.full
- AAFP 2010. http://www.aafp.org/afp/2010/0815/p361.html
- Pract Neurol 2008. Link.