Don’t Dread DizzinessDescribe the dizziness and other symptoms I pass out, feel faint,...

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



when first sit up


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


• 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


• 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



when first sit up



intolerance


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


ConsiderSuperior

SemicircularCanal dehiscence


when first sit up



intolerance




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


Think Meniere’s


ConsiderSuperior

SemicircularCanal dehiscence


when first sit up



intolerance




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



Think Meniere’s


ConsiderSuperior

SemicircularCanal dehiscenceI am older

And am unsteadyOn my feet

Presbystasis(disequilibrium of aging)


when first sit up



intolerance




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



Think Meniere’s

One main episodeOf vertigo, n&v

Think vestibularneuritis


ConsiderSuperior





when first sit up



intolerance




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



Think Meniere’s




Spin when Roll over in bed

BenignPositional

vertigo

ConsiderSuperior





when first sit up



intolerance




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



Think Meniere’s




Spin when Roll over in bed

BenignPositional

vertigo

ConsiderSuperior





when first sit up



intolerance




Don’t Dread DizzinessDescribe the dizziness and other symptoms I pass out, feel faint,...

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