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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
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Sources
Cummings Otolaryngology – Head & Neck Surgery 6th Edition
UpToDate.com
Dizziness-and-balance.com
Evaluation and Treatment of Dizzy Patient - Halifax
Otolaryngology Review Course