Approach to Dizziness December 4, 2001 Swedish Family Medicine Dobrina Okorn, MD

Clinical Scenario  It’s 2:50pm and your 2:45 is being placed in a room. Your next patient is scheduled at 3:00pm and you’ve given up trying to dictate between patients. Your nurse hands you the chart, on the front of which the chief complaint and blood pressure are written: “Dizziness”, 148/86. You emit an almost-silent groan and gather your thoughts before entering the room.

Differential  40% Peripheral vestibular dysfunction  10% Central brainstem vestibular lesion  25% Presyncope or disequilibrium  15% Psychiatric disorder  10% Unknown cause

Case continues...  You quickly review the chart and see that the pt is a 47 yo gentleman with no significant PMH (he was last seen one year ago for a mole removal) and is on no medications; you enter the room.  He tells you that last week, all of a sudden, he was attacked by episodes of dizziness -- yeah, the room was spinning around him, how did you know? -- sometimes just while standing still, sometimes when he turned over in bed. Each lasted less than a minute or two and then he’d be fine.

Vestibular dysfunction...  Peripheral causes  canalithiasis (BPPV) %  vestibular neuronitis (labyrinthitis) -- 25%  Meniere’s disease -- 10%  trauma  drugs (aminoglycosides)  Central causes  vascular (vertebrobasilar insufficiency) -- 50%  demyelinating (multiple sclerosis)  drugs (anticonvulsants, alcohol, hypnotics)

Vertigo vs. other types of dizziness  Time course -- vertigo is never continuous  Provoking factors -- spontaneously or with positional changes  Aggravating factors -- all vertigo is made worse by moving the head

Establishing the cause of vertigo (Pt 1)  Time course  BPPV: lasts less than one minute, self- limited, responds poorly to anti-vertigo drugs  Vascular: single episode lasting minutes to hours; usually due to migraine or to transient ischemia of the labyrinth or brainstem; occasionally Meniere’s disease  Recent onset of more prolonged episodes characteristic of vestibular neuronitis, multiple sclerosis, vertebrobasilar ischemia

Establishing the cause of vertigo (Pt 2)  Associated symptoms  Vertebrobasilar stroke: diplopia, dysarthria, dysphagia, weakness, numbness  Meniere’s disease: aural fullness, deafness, tinnitus  Psych/Panic attack: SOB, palpitations, diaphoresis  Multiple sclerosis: vertigo preceded by other neurologic dysfunction

Establishing the cause of vertigo (Pt 3)  Prior risk factors  migraine  HTN, DM, smoking, PVD  head injury  psychiatric illness

Physical exam  Vestibular exam  Neurologic exam  Severity of postural instability  Hearing tests

Peripheral vs Central Vertigo

Dix-Hallpike Maneuver

Peripheral vs Central Nystagmus

Further studies to evaluate vertigo  MRI/MRA -- distinguishing central causes  Audiometry -- distinguishing peripheral causes  Brainstem evoked audiometry % sens for detecting acoustic neuromas

Management of Vertigo  Treat the underlying disease  migrainevertebrobasilar ischemia  multiple sclerosiscerebellar tumors  Meniere’s disease: low salt diet, diuretics  Vestibular neuronitis (labyrinthitis): antibiotics rarely needed  BPPV: particle-repositioning maneuvers

Particle - repositioning maneuver

Management of Vertigo  Treat the underlying disease:  migrainevertebrobasilar ischemia  multiple sclerosiscerebellar tumors  Meniere’s disease: low salt diet, diuretics  Vestibular neuronitis (labyrinthitis): antibiotics rarely needed  BPPV: particle-repositioning maneuvers  Drug therapy, physical therapy

And the case starts over...  You quickly review the chart and see that the next pt is a 30 yo woman seen multiple times over the past years for LLQ pain, headache, allergies, and intermittent knee pain.  She states “I’ve been feeling dizzy.” It comes and goes, lasts up to 20 minutes, and gradually goes away.

Nonspecific dizziness  psychiatric disorders  major depression 25%  generalized anxiety or panic disorder 25%  somatization disorder  alcohol dependence  personality disorder  hyperventilation  overlap with presyncope: CAD, CHF, PE, dysrhythmias

And the case begins again...  You walk into the room of a 72 yo gentleman who tells you that he’s been feeling dizzy for the past few months. It happens throughout the day but is even worse when he has to get up to go to the bathroom in the middle of the night.

Disequilibrium  multisensory disorder due to any combination of:  peripheral neuropathy  visual impairment  musculoskeletal disorder interfering with gait  vestibular disorder  cervical spondylosis

Disequilibrium guidelines  inquire about neurologic and gait disorders  medications, especially antidepressants and anticholinergics  falling or dizziness while driving (needs intervention)

Presyncope  “nearly blacking out”, “nearly fainting”  lasts seconds to minutes  orthostatic hypotension  cardiac arrhythmias  vasovagal attacks

Summary  Elucidate by history and confirm by physical  Majority of pts have vertigo, followed by nonspecific dizziness and disequilibrium  Most causes are benign and self-limited  Serious causes suspected by unilateral hearing loss, abnormal neurological exam, or evidence of a central as opposed to peripheral cause of vertigo