How to diagnose dizziness without getting one

How to diagnose dizziness

without getting one !

Nassif Mansour

GPwER - SW London

One Day Essential | Neurology Friday 25 January 2019

• You can actually diagnose dizziness

• How best to manage your patients

• To develop your management pathways

to improve your local service

Objectives

• 0.5 - 5% of consultations in general

practice

• 20 - 30% of referrals to Neurology

Departments

• Common referral to ENT

• 90% of patients with dizziness have

BPPV, Postural Hypotension or

Vestibular Migraines

Dizziness

What do they actually mean !

• Vertigo : Illusion of rotation or

movement

• Light headedness, giddiness,

funny turn, disorientation, muzzy head

• Near faint Pre-syncope

What do they actually mean !

ABC

• Onset

• Pattern

• Duration

• Intensity

• Precipitating / aggravating factors

• Positional / Postural

• Relieving factors

• Associating features

• Poor balance / Falls

• Headaches

• Nausea / Vomiting

• Tinnitus / Hearing loss

• Photo / Phonophobia

ABC

Symptoms V. Neuritis /

Labyrinthitis

Onset Acute

Intensity

&

Duration

Severe

Days -Wks

Pattern Continuous

Tinnitus Likely

Headache Flu-like

Other Features Disequilibrium


Labyrinthitis

CVA

Onset Acute Acute

Intensity

&

Duration

Severe

Days - Wks

Severe

Days - Wks

Pattern Continuous Continuous

Tinnitus Likely Unlikely

Headache Flu-like 40% of Post. Circulation

CVAs

Other Features Disequilibrium Disequilibrium


Labyrinthitis

CVA Vestibular Migraines

Onset Acute Acute Subacute

Intensity

&

Duration

Severe

Days - Wks

Severe

Days - Wks

Moderate

Hrs - Days

Pattern Continuous Continuous Episodic

Tinnitus Likely Unlikely Less likely

Headache Flu-like 40% of Post.

Circulation CVAs

Common

Other Features Disequilibrium Disequilibrium Migraine related


Labyrinthitis

CVA Vestibular Migraines Meniere’s

Onset Acute Acute Subacute Subacute

Intensity

&

Duration

Severe

Days - Wks

Severe

Days - Wks

Moderate

Hrs - Days

Mod – Severe

Mins to hours

Pattern Continuous Continuous Episodic Episodic

Several a day

Tinnitus Likely Unlikely Less likely Common


Circulation CVAs

Common Fullness

Other Features Disequilibrium Disequilibrium Migraine related Loss of hearing


Labyrinthitis

CVA Vestibular Migraines Meniere’s BPPV

Onset Acute Acute Subacute Subacute Acute but positional

Intensity

&

Duration

Severe

Days - Wks

Severe

Days - Wks

Moderate

Hrs - Days

Mod – Severe

Mins to hours

Mod – Severe

Secs - Mins

Pattern Continuous Continuous Episodic Episodic

Several a day

Episodic

Several a day

Tinnitus Likely Unlikely Less likely Common Unlikely


Circulation CVAs

Common Fullness Unlikely

Other Features Disequilibrium Disequilibrium Migraine related Loss of hearing None

• 20-60% of causes of vertigo

• All ages, peak @ 60

• Vertigo, light-headedness, imbalance, nausea

• Ppt by activities like

Turning in bed

Getting out of bed

Looking sideways

Looking up “top shelf vertigo”

Bending down

• Causes

50% idiopathic

Head injury

Vestibular neuritis / Meniere's

Surgery – dental treatment, Mastoidectomy

Gentamicin toxicity

Benign Paroxysmal Positional Vertigo - BPPV

• Orthostatic Hypotension

• Cardiac dysrhythmias

• Vaso-vagal

Pre-Syncope

• Cross-sectional diagnostic study 417

patients ages 65 – 95 yr with dizziness

• Half had more than one cause

• Causes:

• Cardio-Vascular 60%

• Vestibular 15%

• Psychiatric illness 10%

• 25% had medications related side effects

Ann of Fam Med May 1, 2010 vol.8 #3 196-205

Older People & Dizziness

• Take history (ABC)

• Medications Review

What do you need to do ?

Meds Dizziness

• Psychotropics

• Antidepressants

• Benzodiazepines

• Pain killers

• Antimuscarinics

• Cardio-vascular

• Diuretics

• Oral Hypoglycaemics

• Anti-epileptics

• PPIs and H2Blockers !

Meds Dizziness


• Take history (ABC)

• Medications Review

• Check Pulse & BP(sitting & standing after 1-2mins)

• Nystagmus

• Gait

• Positional test


Dix-Hallpike testDix-Hallpike test

Please Insert Video Here

Management

• BPPV – Postional Manoeuvre, 80% success rate

• Pre-syncope - ECG and/or 24hr ECG

• Meniere’s disease (actually quite rare);

• Reduce salt, chocolate, red wine

• Bendroflumethiazide 2.5mg

• Betahistine 8-16mg tds (prophylaxis)

• Labyrinthitis/neuritis

• Short term only cinnarizine or prochlorperazine

• Migraine – usual prophylaxis (TCA)

• Refer

• Acute CVA suspected – 999

• If can’t be 100% sure it is not CVA – Stroke/TIA pathway

• Cardio-vascular – Cardiologists

• Migraines – Neurologists

• Not responding, Not sure - Audio-Vestibular

• Chronic Dizziness & Disequilibrium – Physiotherapy

Management

Epley Manoeuvre Epley Manoeuvre

Please Insert Video Here

In summary

• Dizziness is a non-specific term

• 90% caused by BPPV, Postural Hypotension and Migraines

• Difficult to differentiate between Acute VN and Stroke

• Always consider BPPV but review medications and exclude

cardio-vascular causes in elderly patient with dizziness

• BPPV is the usual cause of recurrent/episodic dizziness, post

head injury, even in those who had labyrinthitis

• 80% of BPPV can be cured in 3 mins

• Vestibular Rehabilitation can restore ADL in 80% of patients

with chronic dizziness

In summary

How to diagnose dizziness without getting one

Documents

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