Dizziness and Vertigo

Overview

Categories
- Dizziness without vertigo, e.g. lightheadedness and presyncope
- Vertigo/disequilibrium: Spinning or rocking sensation
Determine episodic versus continuous
- Episodic
  - Triggered: Brief episodes with sudden head movement or position change
  - Spontaneous: No identifiable trigger and last seconds to days
- Continuous: Lasting days to weeks
Physical exam: Orthostatic vitals, otoscopy, hearing, HINTS, Dix-Hallpike, Romberg, gait
Consider additional testing based on suspected etiology
- Electrolyte disturbance: CMP
- Ear pathology associated with hearing loss: Audiometry
- Presyncope (cardiac): EKG, Holter monitor, carotid artery doppler
- Neurologic findings on exam (see below): CT angiography vs. MRI
See AAFP diagnosis flowchart

Benign paroxysmal positional vertigo (BPPV)

Triggered vertigo with negative Dix-Hallpike

Vestibular neuritis
- Second most common vertigo etiology and can produce continuous symptoms (see below)
- Pathophysiology: Inflammation of vestibular nerve or labyrinthe organs often precipitated by viral infection
- May produce oscillopsia (movement of objects in visual field) and falls to affected side
- Start vestibular suppressant medication x 3 days (choose one) and refer to vestibular physical therapy
  - Meclizine (Antivert) 12.5 mg q8h PRN (MDD 100 mg)
  - Metoclopramide (Reglan) 5 mg q6h PRN (MDD 60 mg)
  - Lorazepam (Ativan) 1 mg q4h PRN (MDD 4 mg)
- Counseling
  - Underlying nerve damage may last two months and symptoms may persist for several months after nerve recovery
  - Prolonged use of antiemetics and antinausea medications may prevent recovery by blocking central compensation
  - If duration of attacks does not decrease during recovery, condition may be due to alternate etiology
Orthostatic hypotension
- Perform orthostatic vital signs (positive if diastolic decreases by 10 mmHg, systolic decrease by 20, and/or HR increases by 30 BPM)
- Negative orthostatic vital signs: Consider vestibular neuritis (see below) versus other syncope etiologies

Meniere’s disease
- Most common ages 20-60 years
- Pathophysiology: Excessive endolymphatic pressure
- May result in falls
- Diagnosis
  - At least two vertigo episodes lasting 20+ minutes each
  - Headache, aural fullness, tinnitus often worse during an attack
  - Audiometry demonstrates unilateral hearing loss
- Treatment: Restrict salt (< 2 g daily), nicotine, and alcohol use
  - Refer for vestibular rehabilitation therapy and follow-up in 6 weeks
  - Acute attacks: Prochlorperazine 5 mg q4h (MDD 40 mg)
  - Chronic management: HCTZ 25 mg/triamterene 37.5 mg qd
  - Refractory symptoms: Refer to ENT for evaluation and potential transtympanic injections with glucocorticoids or aminoglycosides
Vestibular migraine
- History of migraine headache
- No confirmatory tests exist, but consider ruling out other conditions, e.g.
  - Audiometry to rule out hearing loss associated with Meniere’s disease (see above)
  - Initial episode lasting longer than 1-2 minutes: MRI with diffusion-weighted imaging and MRA of the posterior circulation to rule out vascular/structural brainstem disease
- Treat migraine headache
Otosclerosis
- Etiology: Abnormal bone growth in middle ear
- Presenting with conductive hearing loss
Psychiatric: Occurs during panic attacks
- Perform PHQ-9 and GAD-7
- Escitalopram 10 mg daily for one week and then increase to 20 mg daily
- Hydroxyzine 25 mg q8h PRN acute anxiety
- Refer for cognitive behavioral therapy
- Follow-up in 4-6 weeks

Associated with trauma or toxin

History of barotrauma
Medications
- 23% of all dizziness cases in elderly
- Often related to aminoglycosides, agents with cardiac effects, muscle relaxants, antispasmodics, antiepileptics, benzodiazepines, alcohol/recreational drugs

Spontaneous onset: Perform HINTS exam

Peripheral
- Saccade with head impulse, unidirectional nystagmus, no skew with eye covering
- Consider vestibular neuritis
Central
- No saccade with head impulse, bidirectional nystagmus, vertical skew with eye covering
- Consider stroke or TIA

HPI
- Onset, frequency, and appearance of vomitus including presence/absence of blood
- Factors that make nausea/vomiting better or worse
- Recent trauma, illnesses, sick contacts, contaminated food/water consumption, travel
- Currently or potentially pregnant
- New medications
ROS: Fever, chills, cough, dyspnea, chest pain/burning, abdominal pain, diarrhea, constipation, dysuria, jaundice, vertigo
PMH: Previous vomiting, GERD, liver/gallbladder disease, diabetes mellitus, stroke
PSH: Cholecystectomy or other abdominal/bowel surgery (adhesion risk)
SH: Use/discontinuation of alcohol, cannabis, or other recreational drugs

Rule out
- Pregnancy in female of childbearing age
- Iatrogenic: Chemotherapy, opioid analgesics, SSRIs, GLP-1 agonists (e.g. exenatide)
Acute on chronic
- GERD
- Cannabis hyperemesis
- Cyclic vomiting syndromes (rare): See pediatric and adult guidelines
Acute onset: Evaluate associated symptoms
- Diarrhea: Infectious gastroenteritis (e.g. food poisoning)
  - Includes viral (adenovirus, rotavirus, norovirus) and bacterial etiologies
  - Laboratory testing rarely changes management although C. difficile toxin fecal lactoferrin, stool culture, stool ova and parasites may be considered
  - Treatment: Generally symptomatic (see infectious gastroenteritis for antibiotic indications)
- Constipation
  - Small bowel obstruction
  - Gastroparesis (e.g. DM complication)
- Abdominal pain +/- jaundice
  - Acute hepatitis
  - Hepatobiliary obstruction/infection
- Vertigo and/or gait instability
  - Vestibular neuritis (labyrinthitis)
  - Cerebellar stroke
- Severe infection/sepsis: Consider pneumonia, pyelonephritis, UTI, etc.
- Trauma with head injury (increased intracranial pressure)
- Acute intoxication or withdrawal