Dizziness/vertigo

“Tell me about it”

Vertigo Pseudovertigo
 Episodic sudden Giddiness Syncopal episodes Disequilibrium
sensation of circular  Sensation of  Sensation of  Loss of
motion of body or uncertainty or ill impending fainting balance/instability
surroundings defined light or LOC while walking
 Accompanied by headedness  Common causes: without sensations
nausea, vomiting,  Not associated with o Cardiogenic of spinning
pallor, sweating, rotation, tinnitus, disorders  Feeling underneath
tinnitus, hearing deafness, n, v o Postural feet is unsteady
disorder hypoTN  Neurogenic origin
 Precipitated by o Drug-
standing, turning induced
head, movement

DDX:

Common  DM (due to hypoglycaemia from therapy or autonomic neuropathy)

benign  Hyperventilation associated with anxiety/phobia  giddiness
condition for  Simple syncope (vasovagal)  syncope
dizziness  Postural hypoTN (drugs, old age)  giddiness, syncope
 Inner ear infection
 Wax in ears
 Post head injury
 Motion sickness
 Alcohol intoxication
Vertigo Peripheral Central
 Benign paroxysmal positional vertigo  Brain stem: vertebrobasilar
(BPPV). Some are associated with insufficiency, infarction, MS
cervical spine dysfunction.  Cerebellum: tumour
 Acute vestibulopathy (vestibular  Tumour: acoustic neuroma,
neuronitis) medulloblastoma, posterior fossa
 Viral labyrinthitis (whole inner ear tumour, secondary brain tumour from
involved: deafness + tinnitus + vertigo) lung mets
 Vestibular migraine
 Meniere’s syndrome
 Drug: alcohol, a/b, antidepressant,
anti-epileptics, antiHTN, diuretics,
tranquilisers
 Trauma
Recurrent  Meniere’s syndrome
spontaneous  Vestibular migraine
vertigo
DDX for vertigo

Acute  Causes:
vestibulopathy o Vestibular neuronitis (acute vertigo + n + v)
o Labyrinthitis (acute vertigo + n + v + hearing loss +/- tinnitus)
o Stroke – AICA, PICA
 Single attack vertigo, without tinnitus or deafness. Abrupt vertigo, ataxia, n, v
 Lateral or unidirectional nystagmus
 Tx:
o Rest in bed, lie still
o Gaze in direction that eases symptoms

BPPV  Induced by changing head position: tilting head backwards, from recumbent
to sitting position or turning to affected side
 Attack is brief, 10-60 secs and subsides rapidly
 No v, tinnitus, deafness
 Spontaneous recovery in a week
 Test of hearing and vestibular function is normal
 Hallspike test (+) indicative of (+) BPPV
  Mx:
o Explanation, reassurance
o Avoidance measures: move in a way that avoid the attack
o Drugs recommended:
 Betahistidine dihydrochloride 24mg BD x 2/52
 Cinnarizine 15mg TDS x2/52
o Special exercise
o Cervical traction may help
o Particle repositioning manoeuvres aka Epley manoeuvre: as tx in a
positional exercise that induce vertigo  hold at this position until it
subsides  repeat until it does not cause vertigo  subside in a few
days
Meniere’s syndrome  Paroxysmal attack of vertigo, tinnitus, n, v, sweating and pallor, deafness
(build up pf (progressive)
endolymph)  Abrupt onset – patient fall and bedridden for 1-2 hours
 Last 30 minutes to several hours
 Nystagmus during attack
 Examination:
o Sensorineural deafness (low tones)
o Caloric test: impaired vestibular function
o Audiometry: sensorineural deafness, loudness recruitment
o Special test
o Characteristic changes in electrocochleography
Vestibular migraine  Past/family history of migraine
(migrainous vertigo)  History of recurrent spontaneous vertigo or ataxia in absence of aural
symptoms
 Vertigo can replace symptoms of headache
 N, v
 Prophylaxis: pizotifen, propranolol
Hx:

 Vertigo or pseudovertigo?
 Symptoms: paroxysmal or continuous? Effect of position or change of posture?
 Any aural symptoms? Tinnitus? Deafness?
 Any visual symptoms?
 Any neurological symptoms?: complex partial seizures, multiple sclerosis (sudden onset vertigo with
jiggly vision but no auditory symptoms)
 Nausea? Vomiting?
 Symptoms of psychoneurosis?
 Any recent cold?: sudden attack of vertigo in a young person following a recent URTI is suggestive of
vestibular neuronitis
 Any recent head injury?
 Any drugs?

Investigations:

Blood test Haematology

 Anaemia: exacerbates dizziness
 MCV (alcoholism)
 Vitamin B12 (deficiency)
Biochemistry
 Glucose (hypoglycaemia)
 LFT (alcoholism)
 Salicylate levels
Microbiology  Gentamycin levels
 Syphilis serology
ECG Cardiac arrhythmia
Audiometry Associated hearing loss
Radiology CT: haemorrhage, SOL
MRI:
 Demyelination
 Acoustic neuroma (tinnitus + hearing loss + unsteady gait)
 Ischaemia
 SOL
 Posterior fossa/cerebella lesions eg cerebellar haemorrhage
Others  BP (lying, sitting, standing)
 Hyperventilation
 Head positioning testing