Approach to Dizziness and Vertigo

Differential diagnosis

• Cardiac
  • Arrhythmia
  • Aortic stenosis
  • Hypertrophic obstructive cardiomyopathy
• Neurological
  • Vertebra-basilar insufficiency
  • Multiple system atrophy
  • Chiari malformation
  • Cerebellar stroke
  • Multiple sclerosis
  • Brain tumour
  • Wernicke’s encephalopathy
  • Lateral medullary syndrome
  • Vertebral artery dissection
• Peripheral
  • Vestibular neuronitis
  • Benign paroxysmal positional vertigo
  • Otitis media
  • Meniere’s disease
• Endocrine
  • Hyperglycaemia
  • Hypoglycaemia
  • Addison’s
  • Hyperthyroidism
• Haematological
  • Anaemia
• Dehydration
• Vasovagal
• Drugs
  • Acute alcohol intoxication
  • Phenytoin
  • Anti-hypertensives
  • Ototoxicity from aminoglycosides / vancomycin
  • Illicit drugs such as LSD
• Psychological
  • Hyperventilation
  • Anxiety

History

• Characterise the dizziness
  • Is the room spinning around you?
  • What were you doing when you noticed it?
  • Is the dizziness continuous, or does it come and go?
  • How long does each episode last?
  • Does anything bring it on? For example turning your head?
• Peripheral vertigo
  • Are there any associated symptoms?
  • Do you hear a ringing sound in your ears?
  • Do you ears feel blocked?
  • Have you noticed any discharge from your ear?
  • Have you had a sore throat or runny nose recently?
  • Has your hearing gotten worse recently?
• Central vertigo
  • Did the dizziness come on suddenly?
  • Do you feel nauseous?
  • Have you had any problems with your vision?
  • Do you find you are bumping into things?
  • Do you have a headache?
  • Do you find it difficult to look at light?
  • Is the giddiness worse when you look up?
  • Have you noticed that colours are not as vibrant as before?
  • Have you noticed any numbness in your hands and feet?
• Endocrine:
  • Do you have, or have you ever had diabetes?
  • Are you on any medication for this?
  • Have you noticed that you are excessively thirsty?
  • Do you get up in the middle of the night to pass urine?
  • Have you noticed any change in the colour of your skin?
  • Do you feel unusually tired lately?
• Drugs:
  • Do you take any long-term medication?
    • Specifically, are you on a water tablet?
    • Have you been given any antibiotics recently?
  • Do you use any recreational drugs?
  • Do you drink alcohol?
  • When was your last drink?

Examination

• Pulse: rate and rhythm
• Optic nerve
  • Pupils equal and reactive to light?
  • Look for relative afferent pupillary defect (demyelination)
  • Visual fields (posterior circulation stroke)
• Extra-ocular movements
  • Multi-directional nystagmus indicates central vertigo
  • Unilateral nystagmus implies either
    • Ipsilateral cerebellar disease
    • Contralateral peripheral vestibular disease
  • Internuclear ophthalmoplegia (demyelination of medial longitudinal fasciculus)
• Check for facial sensory loss and lower motor neurone facial weakness (cerebello-pontine angle lesion)
• Hearing
  • Screen hearing for sensorineural hearing loss
  • Rinne’s test (compare hearing through air versus bone – mastoid process)
    • Normal: air conduction better than bone conduction
    • Conductive hearing loss: bone conduction better than air conduction
  • Weber’s test
    • Normal: sound is equal in both ears
    • Conductive hearing loss: sound is louder in affected ear
    • Sensorineural hearing loss: sound is louder in the normal ear
• Cerebellar dysfunction
  • Intention tremor
  • Dysmetria
  • Dysdiadochokinesis
• Auscultation
  • Carotid bruits
  • Ejection systolic murmur (aortic stenosis or HOCM)
• Ask for:
  • Vitals
  • Postural blood pressure

Investigations

• Blood tests
  • Full blood count (symptomatic anaemia, polycythaemia can pre-dispose to stroke)
  • Blood glucose
  • Renal panel (raised urea in dehydration or anaemia from gastrointestinal blood loss)
• Electrocardiogram to look for anaemia
  • Holter or REKA if index of suspicion of cardiac arrhythmia is high
• Echocardiogram if clinical examination picks up cardiac abnormality
  • To assess severity of aortic stenosis / left ventricular outflow tract obstruction
• Computed tomography scan of the brain if central vertigo is suspected
• Magnetic resonance imaging of the brain
  • Cerebellopontine angle tumours
  • Demyelination
• Audiometry to delineate hearing loss

Management

• Patient education
• Stroke
  • Thrombolysis if within the thrombolysis window (4.5 hours)
  • Load aspirin and control of cardiovascular risk factors otherwise
  • Decompression if haemorrhagic stroke
• Peripheral vertigo
  • Vestibular suppressants such as antihistamines
  • Epley manoeuvre