A practical approach to dizziness
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A practical approach to dizziness. Michael Gilchrist, MD MPH 8/17/09. Case. 71 year old female with hypertension present to clinic with “dizziness”. What questions would you ask?. Dizziness. Common primary care complaint Vertigo, presyncope, disequilibrium, other. Outline. Presyncope

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A practical approach to dizziness

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A practical approach to dizziness

A practical approach todizziness

Michael Gilchrist, MD MPH


A practical approach to dizziness


  • 71 year old female with hypertension present to clinic with “dizziness”.

  • What questions would you ask?



  • Common primary care complaint

  • Vertigo, presyncope, disequilibrium, other



  • Presyncope

  • Vertigo

    • Causes

    • Characteristics of different causes

  • History and physical

  • Warning signs

  • How to approach the patient?

I m dizzy

“I’m dizzy”

  • Non-specific term

  • Vertigo and psychiatric causes make up the majority of cases seen in clinic setting (55-70%)

  • Multicausal, presyncope, unknown, hyperventilation



  • Prodromal symptom of fainting

  • Usually occurs when patient is standing or upright, not supine

  • Orthostatic hypotension, cardiac arrhythmias, vasovagal attacks most common

Other causes

Other causes

  • Parkinson’s disease

  • Peripheral neuropathy

  • Hyperventilation

  • Medications

  • Hypoglycemia

  • Psychiatric disorders

Vertigo vs presyncope

Vertigo vs. presyncope

  • Positional vertigo and postural presyncope often confused

  • Both can occur when someone goes from sitting to standing

  • Vertigo (especially BPPV) can be provoked with maneuvers that move the head without changing BP



  • Dysfunction of vestibular system (central vs. peripheral)



  • Illusion of motion

    • Self-motion

    • Motion of the surrouding environment

    • “spinning”, “tilting”, “moving”

  • All vertigo is made worse by moving the head.

The history

The history…

  • Patient description (“spinning” sensation, however is non-specific)

  • Time course

    • Vertigo is rarely described as continuous.

  • Hearing loss? If so, duration and progression, unilateral vs. bilateral, tinnitus, sx of otitis

Causes of vertigo


Benign positional vertigo

Vestibular neuritis

Herpes zoster oticus

Meniere’s disease

Labyrinthine concussion

Cogan’s syndrome

Acoustic neuroma

Aminoglycoside toxicity

Otitis media


Migrainous vertigo



Wallenberg’s syndrome

Cerebellar infarcation or hemorrhage

Chiari malformation


Causes of Vertigo

A practical approach to dizziness


  • Most commonly recognized form of vertigo

  • Attributed to calcium debris within the semicircular canal (canalithiasis)

  • “I feel like the room is spinning when I turn my head”

  • Lasts seconds, but pt may feel destabilized for hours after an attack

  • No ear pain, tinnitus, or hearing loss

Bpv cont

BPV (cont.)

  • Diagnosis usually made by history

  • Dix Hallpike maneuver

    • Positive in 50-80% of patients

  • Canalith repositioning maneuvers

  • Medical therapy usually not helpful due to transient symptoms

Vestibular neuritis

Vestibular neuritis

  • Viral or postviral inflammatory disorder

  • Rapid onset of severe persistent vertigo with nausea, vomiting, ataxia

  • Sometimes combined with unilateral hearing loss (labyrinthitis)

  • Steroid taper.

  • Dramamine, meclizine (H1 blockers), benzodiazapines

Herpes zoster oticus

Herpes zoster oticus

  • AKA Ramsay Hunt syndrome

  • Activation of latent herpes zoster infection

  • Vertigo + hearing loss, ipsilateral facial paralysis, ear pain, vesicles

  • Antiviral therapy

Meniere s disease

Meniere’s disease

  • Excess endolymphatic fluid pressure

  • Episodic, acute vertigo, lasts minutes to hours

  • Unilateral tinnitus, hearing loss, ear fullness

  • Treatment

    • Salt, caffeine, tobacco restriction

    • Diuretics

    • Surgical

Labryinthine concussion

Labryinthine concussion

  • Traumatic vestibular injury following head trauma

  • Transverse fractures of the temporal bone

Cogan s syndrome

Cogan’s syndrome

  • Autoimmune

  • Similar to Meniere’s: veritgo, ataxia, nausea, vomiting, tinnitus, hearing loss

  • “oscillopsia”: perception of objects jiggling after abruptly turning the head

Acoustic neuroma

Acoustic neuroma

  • Slow growing tumor

  • Patients often experience mild vertigo or no vertiginous symptoms at all

  • Unilateral tinnitus and hearing loss

  • MRI brain

Otitis media

Otitis media

  • Fever, hearing loss, nausea, vomiting

  • If pt has pain with tragal stimulation, consider CT scan of face to evaluate for labryinthine fistula in the temporal bone

Peripheral causes

Peripheral causes

  • Benign positional vertigo - most common, no hearing loss

  • Vestibular neuritis - sometimes hearing loss

  • Herpes zoster oticus (Ramsay-Hunt)

  • Meniere’s disease - unilateral hearing loss

  • Labyrinthine concussion

  • Cogan’s syndrome - autoimmune

  • Acoustic neuroma - often minimal vertigo

  • Aminoglycoside toxicity

  • Otitis media

Central causes

Central causes…

Migrainous vertigo

Migrainous vertigo

  • Can have central and peripheral manifestations

  • Diagnosis made by history (aura, headache

  • Sometimes associated with migraine headaches

Brainstem ischemia

Brainstem ischemia

  • Vertebrobasilar arterial system

  • Rarely the sole manifestion, however

  • MRI brain

Wallenberg s syndrome

Wallenberg’s syndrome

  • Lateral medullary infarction

  • Posterior inferior cerebellar artery

  • Oftentimes concurrent

    • Ocular movements

    • Ipsilateral Horner’s syndrome

    • Ipsilateral limb ataxia

    • Sensory loss

    • Hoarseness, dyphagia (CN IX)

Cerebellar infarction hemorrhage

Cerebellar infarction/hemorrhage

  • Sudden intense persistent vertigo with nausea and vomiting. Pronounced gait abnormalities

  • Pt falls toward the side of the lesion

  • Typically older pts (>60 y/o) with CV risk factors

Warning signs

Warning signs

  • Suggestions of central vestibular disease or brainstem lesions

    • Persistent vertigo

    • Ataxia

    • Nausea/vomiting

    • Headache

    • Vision loss, diplopia

    • Slurred speech

Vertigo physical exam findings

Vertigo, physical exam findings

  • Nystagmus

  • Hallpike maneuver

    • Move patient rapidly from sitting to lying position, head tilted downward of facing you

A practical approach to dizziness

The Dix-Hallpike Test of a Patient with Benign Paroxysmal Positional Vertigo Affecting the Right Ear

Furman J and Cass S. N Engl J Med 1999;341:1590-1596

Central vs peripheral vertigo

Central vs. Peripheral Vertigo

  • Peripheral

    • Nystagmus unidirectional, horizontal with a torsional component

    • Other neurologic signs absent

    • Deafness or tinnitus may be present

  • Central

    • Nystagmus can be in any direction

    • Other neurological signs often present

    • Gait instability

    • Deafness or tinnitus typically absent

    • Often less severe

    • More likely to be chronic, not episodic

High yield historical questions

High yield historical questions

  • Subjective description, avoid leading questions

  • Duration/frequency of symptoms

  • Triggering factors

  • Associated nausea/vomiting?

  • Hearing loss or tinnitus?

  • Any other neurological complaints

  • Recent viral illness, fever, systemic symptoms?

  • New medications?

Physical exam

Physical exam

  • Neurological exam

  • Check for nystagmus with and without Dix-Hallpike

  • Ear exam

  • Gait

  • Cardiovascular exam

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