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Dizziness and Vertigo

DALHOUSIE FALL REFRESHER – NOVEMBER 29, 2019

DR BLAIR WILLIAMS MD FRCSC

OTOLARYNGOLOGY – HEAD & NECK SURGERY

Disclosure Slide

No relevant disclosures

Objectives – Dizziness and Vertigo

To differentiate vertigo from other

types of dizziness

To determine whether vertigo is of

central or peripheral origin

To describe the presentation and

treatment of peripheral vestibular

conditions

Dizziness

This is a non-specific term

Light headedness

Presyncope

Vertigo

Ataxia

Unsteadiness

Dysequilibrium

A more specific description guides approach to investigation and treatment

Balance

-Visual

-Propriocept

-Somatic sensation

-Vestibular

Sensory

Input

-Brainstem

-Cerebellum

-Cortex

Sensory Integration

-Muscle tone

-Balance

Output

Vertigo

The sensation of movement in the absence of movement

Most commonly spinning

Typically vestibular in origin – inner ear, CN VIII, brainstem nuclei

Vertigo

The sensation of movement in the absence of movement

Most commonly spinning

Typically vestibular in origin – inner ear, CN VIII, brainstem nuclei

History is the key to diagnosis

Features of the sensation

Timing of the episodes

Associated symptoms

Triggers

Dizziness – Vestibular origin or not?

Vesitbular

Vertigo

Episodic

Vomiting

Otologic Symptoms

Worse with head movement

Other

Lightheadedness

Chronic disequilibrium

Cardiac symptoms

Neurologic symptoms

Loss of Consciousness

Features Suggesting Central

Vertigo

Five “D’s”

Dysarthria

Dysphagia

Dysmetria

Diplopia

Downbeating or

Direction changing

nystagmus

Hemifacial or hemibody

sensory or motor deficit

Drop attacks, visual loss,

confusion

Unlikely peripheral with

these features!

Acute Vertigo – Central vs

Peripheral

HINTS Study Kattah et al, 2009. Stroke.

Acute Vertigo Presentation

N=101, 25 vestibular and 76 central

Bedside exam and imaging for

everyone

A normal HINTS test correctly ruled

out stroke at 96%, superior to MRI with

DWI (12% false negative)

HINTS Exam

Absence of ALL of

these features (IN-

FA-RCT) essentially

rules out a central

etiology

Peripheral Vestibular Conditions

Vertigo Differential Diagnosis

Timing Hearing Preserved Hearing Loss

Seconds - Minutes BPPV

Minutes - HoursVestibular

MigraineMeniere’s Disease

Days Vestibular Neuritis Labyrinthitis

Seconds to Minutes - BPPV

Benign Paroxysmal Peripheral Vertigo

Loose otoconia in semi-circular canals

Continued stimulation after head movement stops

Diagnosed by moving the otoconia

Treated by guiding the otoconia to the utricle

Semicircular Canal Physiology

BPPV

Most common cause of

vertigo

Brief, intense episodes

Rolling over, tilting head back,

etc

Also the best: often can be cured

in the office

No meds, no scans

https://www.dizziness-and-balance.com/sitedvd.htm

BPPV – Posterior Canal

Dix Hallpike (Diagnosis)

BPPV – Posterior Canal

Epley (Repositioning)

BPPV – Home Exercises

https://www.uptodate.com/contents/images/NEURO/63738/Brandt_Daroff_maneuver.jpg

Brandt-Daroff

https://www.uptodate.com/contents/images/NEUR

O/63738/Brandt_Daroff_maneuver.jpg

Thought to work through habituation

rather than repositioning

Repeat 10-20x per session

Up to 3x per day

Minimal evidence to support

High rate of spontaneous resolution in

BPPV

Home Epley more effective, needs

instruction

BPPV Summary

Free particles in the semicircular canals

Diagnosis and treatment at bedside

No need for imaging

No need for meds

Low threshold to try the maneuvers

Physiotherapists trained in vestibular rehab are

really good at this!

Minutes to Hours: Meniere’s & Migraine

Meniere’s Disease

Episodic vertigo (20 minutes to hours)

Transient hearing loss, tinnitus, aural fullness with the vertigo

Typically unilateral

Thought to arise from endolymphatic hydrops

Still poorly understood despite being described >150 years ago

Treatment aims to prevent distension of the endolymphatic

sac

Meniere’s Disease

Hearing loss

fluctuates with

episodes

Low frequency loss

develops over time

https://entokey.com/wp-

content/uploads/2016/06/9781604064759_c027_f001.j

pg

Meniere’s Disease

Serc (betahistine) is typically first line:

Not given routinely for anything but Meniere’s

Works best as a preventive medication, not

PRN

Start as low as 8 mg TID, safe in higher doses

Thiazide diuretics, low sodium diet, avoid

triggers

Surgery as last resort

Meniere’s Disease Summary

Episodic vertigo lasting hours

Prominent, transient unilateral aural

symptoms

Hearing loss, tinnitus, fullness

Audiogram helpful in diagnosis

Treatments address endolymphatic hydrops

Regular betahistine dosing first line

Vestibular Migraine

Relatively new diagnosis (15-20

years)

True vertigo, typically lasting hours

Imbalance between episodes

Visual triggers – moving scenes, etc

Other triggers similar to migraine

Sleep deprivation, stress, hormonal

changes

Vestibular Migraine

Typical migraine headache

Not necessarily with vertigo episodes

1+ non-headache symptom

Photophobia, phonophobia, aura

Prominent visual symptoms and

triggers

Far more common than Meniere’s

https://www.mymigrainebrain.com/my-migraine-blog/vestibular-migraine-the-dizzy-monster-in-my-spouse/

Vestibular Migraine

ICHD-3 Criteria for Vestibular Migraine

A. At least five episodes fulfilling criteria C and D

B. A current or past history of migraine without aura or migraine with aura

C. Vestibular symptoms of moderate or severe intensity, lasting between 5 minutes

and 72 hours

D. At least 50 percent of episodes are associated with at least one of the following

three migrainous features:

1. Headache with at least two of the following four characteristics:

a) Unilateral location

b) Pulsating quality

c) Moderate or severe intensity

d) Aggravation by routine physical activity

2. Photophobia and phonophobia

3. Visual aura

E. Not better accounted for by another ICHD-3 diagnosis or by another vestibular

disorder

Good for research,

cumbersome for clinical use!

Vestibular Migraine

Treatment

Little available data (case series and retrospective studies)

Current approach based on other migraine variants

Lifestyle

Adequate rest, exercise, diet

Avoid known triggers

Triptans as an abortive therapy

Prevention

Consider frequency, duration, severity of attacks

Venlafaxine 37.5 mg daily

TCAs, CCBs (flunarizine)

Vestibular Migraine Summary

Suspect if no associated aural symptoms

History of migraine common

Prominent visual symptoms

Often exhibits aura, photo/phonophobia

Typical migraine triggers – avoidance!

Treat as migraine – triptans if infrequent,

prophylacitc meds if frequent and severe

Lasting Days – Vestibular Neuritis

Vestibular Neuritis

Acute onset of severe, unrelenting vertigo for days

Nystagmus, ataxia, nausea/vomiting, intolerance of head movement

Unclear etiology

Neurotrophic virus

Inflammatory, microcirculatory

+/- hearing loss (termed ‘labyrinthitis’ if unilateral SNHL)

Vestibular Neuritis

Self limiting

Rule out ischemic event

Variable recovery in vestibular function

Supportive for a 3-5 days

Steroids, anti-emetics, benzos

Avoid long-term bedrest and vestibular suppressants

Delays adaptation

Acute Treatment of

Vestibular Neuritis

Short term use only

3-5 days

Prolonged use will delay

compensation

No established role for

betahistine

https://www.uptodate.com/contents/vestibular-neuritis-and-labyrinthitis?topicRef=5097&source=see_link#H9

Dizziness Summary

Vertigo versus other cause

If vertigo, central vs peripheral (inner ear)

If peripheral, limited number of causes

Timing is key

Associated symptoms help – dizzy diary

Tailor treatment to the most likely cause

If ineffective, reassess diagnosis and try something else

Key Messages

Rule out central cause

BPPV is most common – no need for Rx or scan

Betahistine - first line only for Meniere’s Disease

Vestibular migraine is more common than Meniere’s – suspect it!

Adaptation is key in vestibular neuritis

Regardless off etiology, vestibular rehab with PT can help most patients

Thank you

Thank you for your attention

Please email me if there are any slides you would like to have sent

bw@dal.ca

Please reach out if you have challenging Otolaryngology cases that you would like to discuss

902-577-2880

Sources

Cummings Otolaryngology – Head & Neck Surgery 6th Edition

UpToDate.com

Dizziness-and-balance.com

Evaluation and Treatment of Dizzy Patient - Halifax

Otolaryngology Review Course