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

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