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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
 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
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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
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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
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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
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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
Furman J and Cass S. N Engl J Med 1999;341:1590-1596
Central vs. Peripheral Vertigo
 Peripheral
 Nystagmus unidirectional, horizontal with a
torsional component
 Other neurologic signs absent
 Deafness or tinnitus may be present
 Central
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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