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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? Synchope/presyncope Dysrhythmias, postural Hypotension, vasovagal This is not vestibular! Think cardiovascular. I pass out, feel faint, Lightheaded, feel dizzy when first sit up Describe the dizziness and other symptoms 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 Synchope/presyncope Dysrhythmias, postural Hypotension, vasovagal I pass out, feel faint, Lightheaded, feel dizzy when first sit up Think Migraine Associated vertigo Light sensitive, Headache, motion intolerance Describe the dizziness and other symptoms 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 Synchope/presyncope Dysrhythmias, postural Hypotension, vasovagal I pass out, feel faint, Lightheaded, feel dizzy when first sit up Think Migraine Associated vertigo Light sensitive, Headache, motion intolerance Consider central causes Neurological workup Dysphagia, paresthesia, Other motor changes Describe the dizziness and other symptoms Central dizziness • Large variety of causes • Workup – symptom appropriate • Stroke, seizures, CNS lesions, MS, etc. Synchope/presyncope Dysrhythmias, postural Hypotension, vasovagal I pass out, feel faint, Lightheaded, feel dizzy when first sit up Think Migraine Associated vertigo Light sensitive, Headache, motion intolerance Consider central causes Neurological workup Dysphagia, paresthesia, Other motor changes Loud sounds Cause dizziness Describe the dizziness and other symptoms Consider Superior Semicircular Canal dehiscence Superior Semicircular Canal Dehiscence • Newly described - 1998 • Noise causes dizziness, sometimes chronic dizziness • Noise with eye movement • May have conductive hearing loss Synchope/presyncope Dysrhythmias, postural Hypotension, vasovagal I pass out, feel faint, Lightheaded, feel dizzy when first sit up Think Migraine Associated vertigo Light sensitive, Headache, motion intolerance Consider central causes Neurological workup Dysphagia, paresthesia, Other motor changes Loud sounds Cause dizziness Describe the dizziness and other symptoms Consider Superior Semicircular Canal dehiscence Repeated episodes, Ear feel full Think Meniere’s Meniere’s Disease (likely not 1 specific disease) • • • • Episodic vertigo Hearing loss Aural fullness Tinnitus Meniere’s Disease Workup • Consider labs to look for metabolic/inflammatory issues (TSH, sed rate, ANA, Comp, FTA-ABS. • Scanning unnecessary unless concerned about central process • Audiometry Meniere’s Disease Management • • • • • • Meclizine or Valium for acute attack 1.5 g sodium diet Low caffeine Dyazide Steroids (oral or transtympanic) Surgery Don’t use regularly Synchope/presyncope Dysrhythmias, postural Hypotension, vasovagal I pass out, feel faint, Lightheaded, feel dizzy when first sit up Think Migraine Associated vertigo Light sensitive, Headache, motion intolerance Consider central causes Neurological workup Dysphagia, paresthesia, Other motor changes Loud sounds Cause dizziness Describe the dizziness and other symptoms Consider Superior Semicircular Canal dehiscence I am older And am unsteady Repeated episodes, On my feet Ear feel full Presbystasis (disequilibrium of aging) Think Meniere’s Presbystasis (not a specific diagnosis) • Diagnosis of exclusion • Is common • Multiple factors – Neuropathy, arthritis, heart disease, vestibular deterioration, visual loss, medications, etc. • Treat specific causes • Physical therapy often helpful Synchope/presyncope Dysrhythmias, postural Hypotension, vasovagal Think Migraine Associated vertigo Light sensitive, Headache, motion intolerance I pass out, feel faint, Lightheaded, feel dizzy when first sit up Consider central causes Neurological workup Dysphagia, paresthesia, Other motor changes Loud sounds Cause dizziness Describe the dizziness and other symptoms One main episode Of vertigo, n&v Think vestibular neuritis Consider Superior Semicircular Canal dehiscence I am older And am unsteady Repeated episodes, On my feet Ear feel full Presbystasis (disequilibrium of aging) Think Meniere’s 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 Synchope/presyncope Dysrhythmias, postural Hypotension, vasovagal Think Migraine Associated vertigo Light sensitive, Headache, motion intolerance I pass out, feel faint, Lightheaded, feel dizzy when first sit up Spin when Roll over in bed Benign Positional vertigo Dysphagia, paresthesia, Other motor changes Loud sounds Cause dizziness Describe the dizziness and other symptoms One main episode Of vertigo, n&v Think vestibular neuritis Consider central causes Neurological workup Consider Superior Semicircular Canal dehiscence I am older And am unsteady Repeated episodes, On my feet Ear feel full Presbystasis (disequilibrium of aging) Think Meniere’s 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 Synchope/presyncope Dysrhythmias, postural Hypotension, vasovagal Think Migraine Associated vertigo Light sensitive, Headache, motion intolerance I pass out, feel faint, Lightheaded, feel dizzy when first sit up Spin when Roll over in bed Benign Positional vertigo Dysphagia, paresthesia, Other motor changes Loud sounds Cause dizziness Describe the dizziness and other symptoms One main episode Of vertigo, n&v Think vestibular neuritis Consider central causes Neurological workup Consider Superior Semicircular Canal dehiscence I am older And am unsteady Repeated episodes, On my feet Ear feel full Presbystasis (disequilibrium of aging) Think Meniere’s
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