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C3 - Dizziness - Approach to Dizziness

Stuart Swadron, MD, FRCPC, Mel Herbert, MD MBBS FAAEM, and Jessica Mason, MD
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C3 - Dizziness Summary 504 KB - PDF

The initial approach to the dizzy patient

Dizziness - C3

Stuart Swadron MD, Jessica Mason MD, Mel Herbert MD

 

* Drug doses are a guide only, always check second source and follow local practice guidelines

 

Take Home Points

      A-B-Cs

      Separate out sick patients with abnormal vital signs first

      Attempt to classify dizziness into a subcategory: vertigo, pre-syncope, disequilibrium, or non-specific dizziness

      Be careful not to push patient into a particular subtype if they don’t quite fit, and be willing to move from one category to another as information changes

      Special attention to the associated symptoms, risk factors, triggers and timing are also important

 

INTRODUCTION

Dizziness is a poorly defined symptom that plagues both patients and clinicians. It is one of the most common chief complaints in both emergency and outpatient settings, accounting for millions of visits to each annually in the U.S. alone.  There is often uncertainty surrounding the clinical approach to the dizzy patient and the wide variation in practices is what makes it particularly difficult for new and seasoned practitioners alike.

 

We are taught that dizziness is a vague term - one that needs to be further qualified in order to be acted upon by the clinician.  Specifically, the patient is asked, “What do you mean by dizzy?”  Only after the patient’s complaint is fit (or pushed!) into one of several categories or subtypes can the clinician begin to evaluate the problem -- at least that is the traditional teaching.

 

THE CLASSICAL SUBCATEGORIES OF DIZZINESS

The classical subcategories of dizziness are defined as follows:

 

1.    VERTIGO: “Do you feel a sense of movement or spinning?” This is considered vertigo.  Typically vertigo is due to a neurological disorder.

 

2.    PRE-SYNCOPE: “Do you feel a sense of lightheadedness or that you are about to faint?”  This is considered  pre-syncope or near syncope.  Typically pre-syncope is due to a cardiovascular disorder.  Some clinicians separate pre-syncope from lightheadedness - pre-syncope being episodic and lightheadedness being continuous.

 

3.    DISEQUILIBRIUM: “Do you feel that you have unsteadiness or trouble sensing your limbs in space (usually manifested by an unsteady gait)?”  This is considered disequilibrium.  Typically disequilibrium is due to a disorder of the spinal cord or peripheral nerves.

 

4.    NON-SPECIFIC DIZZINESS: Some patients seem to defy these classical subcategories and don’t really seem to fit into any of them well - so some clinicians add another subcategory - non-specific dizziness.  This is a term that to some patients appears to overlap with other vague symptoms such as generalized malaise or weakness or simply feeling unwell.  The causes of non-specific dizziness include disorders in all of the systems described above but also include just about every other system from endocrine and metabolic to psychiatric.

 

Sometimes the classical approach can fail us - we get stuck down the wrong path and miss an important diagnosis.  For example, if we miscategorize a pre-syncope patient as vertigo we may miss a life-threatening arrhythmia.

 

In this episode of C3, we use this traditional approach for evaluation of dizziness but we also emphasize the importance of other critical clues: the associated symptoms, timing, triggers, and special physical examination tests.

 

INITIAL STEPS

      Identify critically-ill patients (ABCs)

     A minority of patients with dizziness will be critically ill, with abnormal vital signs and need for acute resuscitation

     These may include patients with acute cardiac, respiratory, metabolic or neurologic emergencies as well as poisonings.

      Cardiac monitor, cardioversion paddles, IV access

     Appropriate in selected patients with abnormal vital signs or who are at high risk for cardiac events

      Supplemental O2

     Appropriate if O2 sat <94%

      ECG

     Important in older patients, those with cardiac disease and in those with abnormal vital signs or presentation suggestive of a cardiac cause (e.g. pre-syncope)

      Medication for Symptoms

     Ondansetron (4-8 mg IV, may repeat) or other anti-nausea medications may be necessary for nausea and vomiting

     Meclizine 25-50 mg PO is often used for symptomatic treatment of vertigo

 

LIFE-THREATENING  DIAGNOSES TO CONSIDER

      Stroke

      Transient Ischemic Attack (TIA)

      Lethal Arrhythmia (e.g. V Tach)

 

EVALUATION OF VERTIGO

1.         Make sure that it’s an isolated neurological feature

 

      Peripheral vertigo is generally more benign.  It is isolated. If any other neurological features are present, we must assume that a central process, such as a stroke or CNS tumor, is present until proven otherwise.

 

      The most important thing that must be established in the evaluation of vertigo is that no other neurological symptoms or findings are present.

 

      This is because it is unlikely for a stroke or other central process to involve only central connections of the vestibular (8th cranial) nerve without also affecting the surrounding structures in the brain -- these nerves are clustered close together in the brainstem.

 

      Check for:

     Diplopia - any double vision on extraocular movement testing (CNs III, IV, VI)

     Dysarthria - any difficulty in speaking or facial asymmetry (CN VII)

     Dysphagia - any difficulty in swallowing (CNs IX and X)

     Dysmetria - (e.g. ataxia) any cerebellar findings (finger-to-nose, heel-to-shin, postural instability)

     Weakness/Sensory loss - any extremity findings from the descending tracts that pass through the brainstem en route to the body

     Walking - patients with peripheral vertigo can present quite dramatically, with nausea and vomiting, and they may appear hesitant or a little unsteady when walking, but they should be able to walk

     Patients with an ataxic gait or those who are unable to walk should be assumed to have a central process

 

2.         The ABCs of isolated vertigo

 

      The ABC’s of isolated vertigo is a mnemonic to remember the three causes of isolated vertigo, with Acute Vestibular Syndrome and Benign Paroxysmal Positional Vertigo being benign, and Central Vertigo being potentially life threatening

      Although most patients with isolated vertigo will be peripheral and safe to discharge home, a small minority will have a central process (e.g. stroke, multiple sclerosis)

      The following table helps distinguish the three main types of isolated vertigo

 

 

THE ABCs of ISOLATED VERTIGO

 

A - Acute Vestibular syndromes (AVS)

B - Benign Paroxysmal Positional Vertigo (BPPV)

C - Central Vertigo (Stroke, tumor, multiple sclerosis)

Etiology

Viral infection

Otoliths (debris) in semicircular canals

Vascular embolus (stroke)

Symptoms

Gradual onset, preceding URI

Brief (<1 minute) episodes with change in head position

Sudden onset, non-fatiguing

Bedside Testing

Reassuring HINTS

Positive Dix-Hallpike Test

Concerning HINTS

Treatment

Corticosteroids, ENT follow-up

Epley or Semont maneuvers

MR, Neurology, Admit (possible tPA)

 

 

      By far the most common cause is BPPV. In order to confidently  “rule in” this diagnosis, all of its classic features should be sought

     A Dix-Hallpike test should only be performed in non-toxic appearing patients with positionally triggered episodic vertigo -- not for patients with constant vertigo or for patients with nystagmus at baseline

     To perform the maneuver the patient starts sitting upright. Their head is turned to one side and then the patient is brought to a supine position with their neck in slight extension. The examiner observes for 30 seconds for nystagmus. Horizontal or rotatory nystagmus is a positive test and helps to confirm the diagnosis of BPPV.

 

      More difficult to differentiate are AVS and Central Vertigo (stroke)

     A sudden onset suggests stroke

     The HINTS test helps differentiate acute vestibular syndrome from a central process (e.g. stroke).

 

The HINTS Test

 

Central

Peripheral

Head Impulse

Turn the patient’s head 10-20 degrees while they maintain a fixed gaze

“Normal” - no saccade correction, stays fixed on you

Dolls eyes that have a saccade correction back to you

Nystagmus

Vertical

Horizontal that changes direction

Horizontal in one direction only

Test of Skew

Alternating covering one eye and then the other in rapid succession

Vertical eye saccade for correction

Normal vertical eye alignment

 

 

EVALUATION OF PRE-SYNCOPE

      In general, the evaluation of pre-syncope is similar to that of syncope - covered in detail in our recent C3

 

EVALUATION OF DISEQUILIBRIUM

      Disequilibrium is much less likely to present acutely to the ED compared to vertigo or pre-syncope because its causes are often chronic

      A loss of proprioception (e.g. a lack of a sense of the extremities in space) may result from a lesion in the posterior columns of the spinal cord or a severe peripheral neuropathy

      Diabetes, chronic vitamin deficiencies and chronic toxicities may all present with a disequilibrium syndrome

 

OTHER IMPORTANT CAUSES

      ENT pathology

     A good head and neck  exam is important - even simple ear wax impaction can cause dizziness which resolves with cleaning

     Ramsay-Hunt and Meniere’s disease may present with hearing loss together with vertigo

 

      Medications

     Medications, especially in the elderly, are a very common cause of dizziness

     A careful medication history is important to identify recent changes that may be responsible for the patient’s symptoms

     Frequently implicated are:

      Cardiac medications, antihypertensives, diuretics, ototoxic medications

      Orthostatic hypotension

     Dehydration, chronic illness, and medications may all contribute to orthostatic hypotension

     Dizziness with postural changes (not just a drop in BP or increase in pulse) are important to make this diagnosis

 

TIMING AND TRIGGERS

     Even when characterization/categorization of the patient’s symptoms is difficult, the timing and triggers of the symptoms can help hone in on the diagnosis

 

Consider the following serious diagnosis

Timing

Continuous

Stroke

Intermittent

TIA

Cardiac arrhythmia

Triggers

No trigger (spontaneous)

Stroke

TIA

Exertional trigger

Cardiac arrhythmia

Positional trigger

Serious causes of orthostatic hypotension

 

 

IMAGING

      CT

     The use of CT in the evaluation of dizziness is generally not indicated but should be considered in those with a new headache and in older, sicker patients

     CT is important to rule out intracranial hemorrhage when it is considered clinically

     CT is not sensitive enough to rule out a stroke in the posterior fossa (where the “dizziness” structures are located ( e.g. cerebellum and brainstem)

      MR

     MR imaging is generally necessary to diagnose acute stroke in the posterior fossa and may be obtained when clinical features are worrisome for stroke. However, MR cannot exclude a stroke diagnosis, particularly in the first 24-48 hours when the sensitivity is lower.

 

THERAPY & DISPOSITION

      Therapies, of course, will vary, depending on where the diagnostic work-up leads

      Most patients with the initial chief complaint of dizziness will be discharged home.

      Expedited work-up in an observation unit, or in lieu of admission, may be appropriate for well appearing patients when there is concern for serious pathology

 

REFERENCES

Bhattacharyya N et al.  Clinical Practice Guideline: Benign Paroxysmal Positional Vertigo (Update).Otolaryngol Head Neck Surg. 2017 Mar;156(3_suppl):S1-S47. doi: 10.1177/0194599816689667.

 

Edlow JA.  A New Approach to the Diagnosis of Acute Dizziness in Adult Patients. Emerg Med Clin North Am. 2016 Nov;34(4):717-742. doi: 10.1016/j.emc.2016.06.004.

 

Muncie HL, Sirmans SM, James E.  Dizziness: Approach to Evaluation and Management. Am Fam Physician. 2017 Feb 1;95(3):154-162. PMID: 28145669

 

3-Component H.I.N.T.S. Battery Video

Video Credit - David Newman-Toker, MD, PhD, Copyright 2009.

David S., Jr -

Excellent! I have to agree, this is the best approach I have encountered. Quick question though, where does an acephalic migraine fit in to this approach as a cause of dizziness?

Jess Mason -

Thanks David. I think for some of these more uncommon etiologies of dizziness, such as vertiginous (vestibular) migraine or possibly acephalic migraines, the ED may not be the best place to diagnose this. If patients are having recurrent episodes of vertigo or dizziness and that is on your differential, perhaps a neurology referral is the next best step. It's hard to fit that into one of the categories Stuart and I discussed, because it may be isolated or there may be associated symptoms, such as tinnitus and various types of nystagmus, and it may be constant or triggered. Of course, if any of the features of a central etiology are present, the patient should still get a work up for cerebrovascular causes, and the final diagnosis can be left for the neurologist at a later time.

David S., Jr -

Sounds great, thanks! Just noticed I typed acephalic instead of acephalgic migraine. The ol' dreaded headless migraine... that is the worst type to figure out :)

Peter Johns, M.D. -

Vestibular Migraine is the second most common cause of vertigo, after BPPV. Knowing the diagnostic criteria for vestibular migraine is the first step to making the diagnosis. Once you know what they present like, you will see them in the ED. The eye only sees what the brain knows.

You do not need to be a neurologist to make this diagnosis, any more than you need to be a neurologist to make the diagnosis of migraine.

David S., Jr -

Dr. Johns, I think your comment gets to my initial concern. I have heard the vertiginous migraines are more common than we once thought. The problem is that they can cause constant symptoms and I cannot figure out how to be certain this isn't from a central lesion. Can you simply rely on the criteria (+headache, +N/V, +Photo/phonophobia, lasting greater than 1min, but less than 72 hours) to accurately diagnosis migraine instead of a TIA or central lesion? Migraine would show up on a HINTS exam like a central lesion, yes? Thanks!

Peter Johns, M.D. -

David S., You had some additional questions which I'll address. There is no imaging that can confirm vestibular migraine. Despite that, it is the most common central cause of vertigo. Just one that almost is never diagnosed in the emergency department, yet no patients have a bad outcome despite this. They just suffer without a proper diagnosis.

HINTS should only be used if the patient has Acute Vestibular Syndrome. ie, continuous, ongoing vertigo AND nystagmus. This was not mentioned in the podcast, but David Newman Toker has said this many times, and it is mentioned in the one of the podcast's references. Most patients with vestibular migraine do not have nystagmus, and so HINTS should not be applied.

I'll outline the most accepted diagnostic criteria here:

Moderate or severe episodes of vertigo lasting 5 minutes to 72 hours
Past or current history of migraine

5 or more episodes of vertigo, at least 50% of which have one of three migrainous features:
1 visual aura, 2 photophobia or phonophobia, 3 Typical migraine headaches

Typical migraine headaches should have at least two of the following four qualities:
1. unilateral, 2. pulsating, 3. moderate or severe intensity, 4. aggravated by routine activity.

In addition, the patient’s clinical presentation should not better accounted for by another headache or vestibular problem.

They key point is they have to have had least 5 episodes of vertigo, with a history of migraine. This makes TIA very much less likely.

Milton S., 4600070 -

A fine job! I enjoyed it.

Jess Mason -

Thanks Milton!

Jonah S., RN -

Great way to remember findings suspicious for central cause on HINTS: HINTS to INFARCT.
IN- Impulse Negative (normal HI)
FA- Fast-phase Alternating (for nystagmus)
RCT- Refocus on Cover Test (for skew deviation)

Also, important to remember to complete entire HINTS exam. For instance, the nerve entry root zone for the eighth cranial nerve is in the lateral pons. These pontine structures are supplied their circulation by the AICA about 80% of the time so an AICA stroke may knock out a unilateral eighth cranial nerve and mimic head impulse findings of a peripheral AVS. Adding hearing loss to the HINTS (what Dr. Newman-Toker calls the HINTS+) helps to uncomplicate this matter but if we just stop after an abnormal vestibulo-ocular reflex we can still miss strokes.

David S., Jr -

To clarify, during the HINTS+ examination, is a HINTS examination consistent with peripheral vertigo (i.e. + head impulse test, as above) and positive for hearing loss considered peripheral or central vertigo? I am assuming the hearing loss with the + head impulse testing means it is peripheral, but I am not certain whether this nerve entry root zone lesion would affect hearing or not based on the comment. Thanks!

Peter Johns, M.D. -

If any of the 4 components of HINTS plus are "central" then you are HINTS plus "central". If you only relied on HINTS with an AICA stroke, you may see an abnormal HIT, and thus think that the patient is (falsely) "HINTS-peripheral". If you test for hearing loss as with HINTS plus, you will find a hearing loss with most AICA strokes, and thus the patient will be correctly identified as "HINTS plus -central". It's actually due to the fact that the AICA supplies the Labyrinthe Artery, so sensory organs of hearing and balance are both affected, leading to an abnormal HIT and hearing loss.

Paul J. V., D.O. -

This was a fantastic explanation of the approach to the dizzy patient. I listened twice today on a long drive. I plan to listen a couple of more times and check out the videos. I have one question regarding HINTS:

Talking about nystagmus, it is abnormal to have the fast component occurring bilaterally. If I'm testing a patient and:
when he looks left he has a right sided nystagmus (fast component to right), and when he looks right he has a left sided nystagmus (fast component to left), is this normal, or would this be abnormal and indicate a possible central lesion?

Jess Mason -

Hi Paul! Yes, the finding you have described is bidirectional nystagmus which is concerning for a central lesion. A peripheral lesion should only cause unidirectional nystagmus.

Dallas Holladay, DO -

Great review, thank you for tackling this daunting topic!

Jonathan S. -

To add to the great comments above, I seem to remember a statement almost in passing in the episode saying that Jess sort of gives the patient a "dry run" of the head impulse test before actually assessing the result. This can give a false result. The saccade of a positive head impulse test is extinguishable, in the same way that Stuart mentions toward the end of the episode that the brain will suppress bad incoming data in a benign peripheral process. Repeated head impulse tests will induce the brain to extinguish the finding, so it is important to pay careful attention with the first head impulse test performed in each direction.

Eric S. -

Any thoughts on CTA head/neck and discharge home if normal in a patient you have a moderate level of suspicion for posterior circulation (cerebellar) etiology? You mentioned non-con CT was around 10% sensitive, any idea of sensitivity with arterial timed contrast? This would allow for reduction of admission to get the MRI in facilities that cannot accommodate MRI in the ER (if sensitivity is adequate).

Benjamin S. -

You had mentioned some links to the HINTS exam in the show notes but I wasn't able to find these. Can you direct me? Thanks, great review!!

Jess Mason -

Thanks Tracy. And also, there is a link to the video all the way at the bottom of the written summary. It's the last thing on the page called "3-Component H.I.N.T.S. Battery Video" by Dr Newman-Toker.

Tracy G. -

Hi Benjamin! The link you are referring to is actually a chart on the HINTS exam. You will find this chart on Page 3 of the written summary.

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C3 - Dizziness Full episode audio for MD edition 90:44 min - 126 MB - M4AC3 - Dizziness - Board Review Answers 178 KB - PDFC3 - Dizziness - Board Review Questions 292 KB - PDFC3 - Dizziness - MP3 Individual Files 122 MB - ZIPC3 - Dizziness Summary 504 KB - PDF