Don’t Dread Dizziness
Lee A. Reussner, M.D.
What is dizziness?
• Syncope• Imbalance• Vertigo• Lightheadedness• Feeling faint• Fuzzy feeling• Dizziness is not a diagnosis!
Dizziness could be:
• Cardiac• Vestibular• Neurologic• Metabolic• Psychiatric• Medication related
Some Causes of Dizziness• Vestibular neuritis• Otitis media• Labyrinthitis• Syphilis• BPV• Meniere’s• Perilymph fistula• Congenital ear abnormality• Acoustic neuroma• Cerebellar lesions• Medications• Ear surgery• Superior semicircular canal
dehiscence• Labyrinthine concussion• Temporal bone fracture• Ramsey Hunt syndrome• Parkinson’s
• Presbystasis• Hypoglycemia• Hypothyroidism• Diabetes• Migraines• MS• Autoimmune diseases• Dysrhythmias• CVA• TIA• Vertebrobasilar ischemia• Postural Hypotension• Hyperventilation• Panic attack• Mal de barquement• Cholesteatoma• Hydrocephalus• Etc.
Listen to your patient, he is telling you the diagnosis.
- Sir William Osler
Evaluation of Dizziness
• History 70%• Physical 10-20%• Tests 10-20%
Biggest Question
Describe your dizziness. What is it like?
Describe the dizzinessand other symptoms
I pass out, feel faint,Lightheaded, feel dizzy
when first sit up
Synchope/presyncopeDysrhythmias, posturalHypotension, vasovagal
This is not vestibular!Think cardiovascular.
Syncope/Presyncope(cerebral hypoperfusion)
• Quite common• Take careful history• 1% of all ED visits• Vasovagal, orthostatic hypotension,
arrhythmias etc.
Brief Postural Hypotension
• May not be able to detect much BP change
• Note medications• Encourage hydration• Compressive stockings
Describe the dizzinessand other symptoms
I pass out, feel faint,Lightheaded, feel dizzy
when first sit up
Synchope/presyncopeDysrhythmias, posturalHypotension, vasovagal
Light sensitive, Headache, motion
intolerance
Think MigraineAssociated vertigo
Migraine Associated Vertigo (MAV)
• 33% with migraines have some vertigo• 3% of US population has MAV• 5-10 times more common than Meniere’s
Migraine Associated Vertigo (MAV)
• Symptoms quite variable• Vertigo lasts seconds to over 24hrs• Often no headache with vertigo• Often history of motion intolerance• Vertigo can be identical to Meniere’s• Ask about family history
Migraine Associated Vertigo (MAV)
• No specific diagnostic tests• Audiogram as for other types of vertigo• Scans and ENG(VNG) not usually helpful• At times patients may be skeptical if have
no headaches
Migraine Associated Vertigo (MAV)Treatment
• Diet• Abortive medications do not work (avoid
Imitrex)• Prophylactic medication
– Verapamil SR 120mg– Nortriptyline 10mg-50mg qhs– Propranolol LA 60mg
Describe the dizzinessand other symptoms
I pass out, feel faint,Lightheaded, feel dizzy
when first sit up
Synchope/presyncopeDysrhythmias, posturalHypotension, vasovagal
Light sensitive, Headache, motion
intolerance
Think MigraineAssociated vertigo
Dysphagia, paresthesia,Other motor changes
Consider central causesNeurological workup
Central dizziness
• Large variety of causes• Workup – symptom appropriate• Stroke, seizures, CNS lesions, MS, etc.
Loud sounds Cause dizziness
Describe the dizzinessand other symptoms
ConsiderSuperior
SemicircularCanal dehiscence
I pass out, feel faint,Lightheaded, feel dizzy
when first sit up
Synchope/presyncopeDysrhythmias, posturalHypotension, vasovagal
Light sensitive, Headache, motion
intolerance
Think MigraineAssociated vertigo
Dysphagia, paresthesia,Other motor changes
Consider central causesNeurological workup
Superior Semicircular Canal Dehiscence
• Newly described - 1998• Noise causes dizziness, sometimes
chronic dizziness• Noise with eye movement• May have conductive hearing loss
Repeated episodes,Ear feel full
Loud sounds Cause dizziness
Think Meniere’s
Describe the dizzinessand other symptoms
ConsiderSuperior
SemicircularCanal dehiscence
I pass out, feel faint,Lightheaded, feel dizzy
when first sit up
Synchope/presyncopeDysrhythmias, posturalHypotension, vasovagal
Light sensitive, Headache, motion
intolerance
Think MigraineAssociated vertigo
Dysphagia, paresthesia,Other motor changes
Consider central causesNeurological workup
Meniere’s Disease(likely not 1 specific disease)
• Episodic vertigo• Hearing loss• Aural fullness • Tinnitus
Meniere’s DiseaseWorkup
• Consider labs to look for metabolic/inflammatory issues (TSH, sedrate, ANA, Comp, FTA-ABS.
• Scanning unnecessary unless concerned about central process
• Audiometry
Meniere’s DiseaseManagement
• Meclizine or Valium for acute attack• 1.5 g sodium diet• Low caffeine• Dyazide• Steroids (oral or transtympanic)• Surgery
Don’t useregularly
Repeated episodes,Ear feel full
Loud sounds Cause dizziness
Think Meniere’s
Describe the dizzinessand other symptoms
ConsiderSuperior
SemicircularCanal dehiscenceI am older
And am unsteadyOn my feet
Presbystasis(disequilibrium of aging)
I pass out, feel faint,Lightheaded, feel dizzy
when first sit up
Synchope/presyncopeDysrhythmias, posturalHypotension, vasovagal
Light sensitive, Headache, motion
intolerance
Think MigraineAssociated vertigo
Dysphagia, paresthesia,Other motor changes
Consider central causesNeurological workup
Presbystasis(not a specific diagnosis)
• Diagnosis of exclusion• Is common• Multiple factors
– Neuropathy, arthritis, heart disease, vestibulardeterioration, visual loss, medications, etc.
• Treat specific causes• Physical therapy often helpful
Repeated episodes,Ear feel full
Loud sounds Cause dizziness
Think Meniere’s
One main episodeOf vertigo, n&v
Think vestibularneuritis
Describe the dizzinessand other symptoms
ConsiderSuperior
SemicircularCanal dehiscenceI am older
And am unsteadyOn my feet
Presbystasis(disequilibrium of aging)
I pass out, feel faint,Lightheaded, feel dizzy
when first sit up
Synchope/presyncopeDysrhythmias, posturalHypotension, vasovagal
Light sensitive, Headache, motion
intolerance
Think MigraineAssociated vertigo
Dysphagia, paresthesia,Other motor changes
Consider central causesNeurological workup
Vestibular Neuritis
• No hearing loss• Thought to be viral• Labs/xrays not helpful• Vertigo can be severe• Most clear within 1 week• Most treatment is symptomatic
Repeated episodes,Ear feel full
Loud sounds Cause dizziness
Think Meniere’s
One main episodeOf vertigo, n&v
Think vestibularneuritis
Describe the dizzinessand other symptoms
Spin when Roll over in bed
BenignPositional
vertigo
ConsiderSuperior
SemicircularCanal dehiscenceI am older
And am unsteadyOn my feet
Presbystasis(disequilibrium of aging)
I pass out, feel faint,Lightheaded, feel dizzy
when first sit up
Synchope/presyncopeDysrhythmias, posturalHypotension, vasovagal
Light sensitive, Headache, motion
intolerance
Think MigraineAssociated vertigo
Dysphagia, paresthesia,Other motor changes
Consider central causesNeurological workup
Benign Positional Vertigo(BPV or BPPV)
• Likely most common cause of vertigo• First described in 1941 – cause was
unknown• Calcium carbonate crystals in semicircular
canals - 1980
epley
epley
Repeated episodes,Ear feel full
Loud sounds Cause dizziness
Think Meniere’s
One main episodeOf vertigo, n&v
Think vestibularneuritis
Describe the dizzinessand other symptoms
Spin when Roll over in bed
BenignPositional
vertigo
ConsiderSuperior
SemicircularCanal dehiscenceI am older
And am unsteadyOn my feet
Presbystasis(disequilibrium of aging)
I pass out, feel faint,Lightheaded, feel dizzy
when first sit up
Synchope/presyncopeDysrhythmias, posturalHypotension, vasovagal
Light sensitive, Headache, motion
intolerance
Think MigraineAssociated vertigo
Dysphagia, paresthesia,Other motor changes
Consider central causesNeurological workup