#49: Vertigo and Dizziness: How to Treat, Who to Send Home and Who Might Have a Stroke

July 24, 2017 | By Matthew Watto, MD

A simplified approach to dizziness/vertigo with tips from international expert, Dr. David Newman-Toker, Professor of Neurology, Ophthalmology and Otolaryngology at Johns Hopkins University. We learn how to differentiate stroke from other causes of dizziness/vertigo; how to approach the differential diagnosis in dizziness/vertigo; how to perform the Dix-Hallpike test, Epley maneuver, and HINTS exam; plus, who benefits from medical therapy and vestibular rehab.

Special thanks to Dr. Cyrus Askin who found our expert, wrote the questions for this episode, and acted as our cohost.

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Case: A 45-year-old man presents to the emergency department because of continuous dizziness, nausea, vomiting and unsteady gait that began 18 hours earlier.

Clinical Pearls:

1. Vestibular system: It’s the 6th sense. Literally! It runs in the background so patients are usually unaware of it, and thus have difficulty describing the sensation of dizziness.
2. Classification of dizziness: Don’t focus on type e.g. vertigo, presyncope, unsteadiness, non-specific other type of dizziness. Focus on timing, triggers, and targeted exam i.e. timing of dizziness, and what triggers the dizziness. These inform the appropriate choice of physical exam maneuvers e.g. Dix Hallpike versus HINTS.
3. All patients with vertigo will feel worse with head movements! The KEY distinction is whether the head movements TRIGGER vertigo (suggestive of episode vestibular syndrome), or EXACERBATE vertigo in a patient w/continuous ongoing vertiginous symptoms (suggestive of acute vestibular syndrome).
4. Buckets: episodic, acute, or chronic vestibular syndromes (see below for detailed description).
5. Episodic vestibular syndrome: Acute vertiginous symptoms present for under 12 hours (usually seconds or minutes). Can be triggered, or spontaneous. Differential diagnosis = benign paroxysmal, positional vertigo (BPPV), vestibular migraine, and Meniere’s disease. If symptoms occur spontaneously (i.e. NOT triggered), then transient ischemic attack must be considered!
6. Acute vestibular syndrome: Persistent vertiginous symptoms 12 hours or more. Differential diagnosis = vestibular neuritis (aka labrynthitis if associated hearing loss) versus stroke.
7. Chronic vestibular syndrome: Symptoms of vertigo lasting one month or more. Many patients had a previous acute vestibular syndrome and never fully recovered. If insidious onset, then suspect an underlying primary neurologic disorder. Some patients have an “anxiety” component w/o underlying pathology (diagnosis of exclusion).
8. Posterior canal BPPV: Most common type. Symptoms triggered by “pitch-plane” movements. e.g. head tipping backwards. Diagnose with Dix-Hallpike (specific for posterior canal BPPV). Treat with Epley maneuver (click here to see video).
9. Horizontal canal BPPV: Less common. Symptoms triggered by horizontal or rotational movements of the head e.g. rolling over in bed. Diagnose with supine roll test (click here to see video). Treatment is similar to Epley, but patient’s head rests on a pillow (rather than hanging from edge of bed) as repositioning maneuver is performed Lempert roll maneuver (see figure 5 in this link).
10. Vestibular migraine: Usually episodic, spontaneous symptoms for many years. Strict criteria require: 1) recurrent episodes of vertigo; 2) a formal migraine diagnosis by International Headache Society criteria; 3) a migraine symptom during the attack (e.g. headache, photophobia, or aura); and 4) the exclusion of other causes (West J Emerg Med 2009).
11. Meniere’s disease: Simultaneous vertigo and cochlear complaints e.g. hearing loss, tinnitus, or aural fullness. Similar to vestibular neuritis, but transient. Usually lasts hours with range 20 minutes to a few days (West J Emerg Med 2009). Meclizine is reasonable choice if limited to 3 days. Chronic therapy can include low salt diet, or ablative procedure like intratympanic gentamicin.
12. Vestibular neuritis: Acute, benign, self-limited condition presumed to be viral or postviral. Dizziness/vertigo is accompanied by nausea or vomiting, unsteady gait, nystagmus and intolerance to head motion. Usually persists for a day or more. It’s called labrynthitis if associated hearing loss). Limit use of benzodiazepines, and meclizine to 3 days. Main therapy is early return to activity, +/- vestibular exercises, or vestibular rehab/physical therapy.
13. Cerebellar stroke: Symptoms can include dysarthria, dysphagia, dysmetria (limb ataxia e.g. clumsiness of arms, or legs), gait unsteadiness, and vertigo. More than 80% lack these classic findings and present with isolated vertigo, nausea, vomiting, unsteady gait, and head motion intolerance. Suggestive exam findings: normal head impulse test, abnormal test of skew, inability to sit with arms crossed, inability to walk without support.
14. Nystagmus: First, check for spontaneous nystagmus as patients look straight ahead. Then, test eye movements in all directions to see if nystagmus changes in direction or intensity.
15. Peripheral nystagmus: Named for the fast movement, which moves away from the affected ear/vestibular nerve. It should never change direction. Usually predominantly in horizontal plane. E.g. Right sided peripheral lesion causes leftward nystagmus (fast movement beating left). It accentuates when looking left, and dampens when looking right. See video example here
16. Bidirectional nystagmus: Direction of nystagmus changes based on direction tested e.g. left beating nystagmus when looking left, but changes to right beating nystagmus when looking right. Often a sign of stroke. See video example here
17. Vestibulo-ocular reflex: Purpose is to keep vision focused on a target during head movement e.g. running, jumping, head turning etc.
18. Head impulse test: Have patient fixate on a midline target (e.g. examiner’s nose). Next, rotate head rapidly 20 degrees to right or left. Then, bring head back to midline. Normal if eyes remain fixed on target. Abnormal if eyes are dragged off target, followed by a saccade back to the target. An abnormal test suggests a peripheral lesion. A normal head impulse test in a patient with an acute vestibular syndrome suggests a stroke. (click to see video here)
19. Test of skew: Alternate cover testing to check for ability to maintain vertical alignment of the eyes. Normal test if no change in alignment with alternate cover testing. If eyes drift in different VERTICAL directions, then this suggests stroke. (click to see video here)
20. Dix-Hallpike: Test for posterior canal BPPV (click to see video here). In a positive test examiner sees a brief (under 10-60 sec) mixed vertical and torsional nystagmus toward the affected ear e.g. nystagmus with fast phase up and to the right if right posterior canal affected.
21. Epley maneuver: Patient’s head is rolled 270 degrees away from the affected ear. Cure for posterior canal BPPV (click here to see video).
22. MRI limitations in posterior fossa: Misses about 20% in first 24 hours, and another 10% in 24-48 hour window. Maximal sensitivity at 72-100 hours. Sensitivity of CT is only 7-16% in acute phase of stroke.
23. Meclizine: Not appropriate for treatment of BPPV given extremely short duration of symptoms. Use Epley maneuver instead. It works! Okay to use meclizine for up to 3 days in acute phase of Meniere’s, or vestibular neuritis (also labrynthitis).
24. Vestibular rehab/exercises: Consider use for patient who cannot tolerate Epley maneuver, or for patients with vestibular neuritis.

Goal: Listeners will recall the pathophysiology/etiology causing common types of dizziness, lightheadedness, and vertigo. They will learn about key parts of the history and physical exam when evaluating these patients along with important imaging studies. They will develop an appreciation for therapeutic interventions – both pharmacologic and non-pharmacologic. They will be able to identify benign etiologies that can be managed on an outpatient basis versus more sinister etiologies requiring an expedited work up.

Learning objectives:
By the end of this podcast listeners will:

1. Recall the three main buckets in patients with dizziness/vertigo
2. Explain the basic pathology and pathophysiology of chronic and recurrent dizziness and/or persistent vertigo.
3. Categorize dizziness/vertigo based on timing, triggers, and a targeted exam
4. Be comfortable with key parts of the history and physical that can help discriminate benign from sinister etiologies (specifically the Dix-Hallpike and HINTS exam)
5. Choose the appropriate test based on type of dizziness/vertigo
6. Determine who requires inpatient admission / stroke evaluation vs. who can be treated as an outpatient.
7. Know what therapeutic modalities (medications or otherwise) are available and when to use them.
8. Identify patients who require consultation with neurology or otolaryngology.

Disclosures:
Dr. Newman-Toker receives federal grant support from the NIH and several other companies. Video-oculography equipment has been loaned to Dr. Newman-Toker for research purposes, but he has no financial interest in these companies. He does occasional medical legal consulting work.

Time Stamps
00:00 Intro
04:16 Getting to know our guest
11:56 Clinical Case
13:13 Why can’t patients describe their dizziness?
15:20 Classifying dizziness
18:35 The 3 vestibular syndrome buckets defined
22:14 Episodic vestibular syndrome differential diagnosis
26:49 Acute vestibular syndrome differential diagnosis
28:08 Chronic vestibular syndrome differential diagnosis
30:15 Challenges of medical history taking
32:10 Approach to the acute vestibular syndrome/HINTS
33:38 How to evaluate nystagmus
38:00 How to perform the head impulse test (aka head thrust)
45:56 How to perform “test of skew” (alternate cover testing)
47:45 Recap of HINTS exam and discussion of MRI
50:50 Signs and symptoms of cerebellar stroke
55:17 Use of Dix-Hallpike for episodic vertigo
57:00 How to perform Dix-Hallpike
59:50 How to perform the Epley maneuver
64:17 What happens when you choose the wrong test
66:10 Continuous versus triggered dizziness, or vertigo
67:40 Meclizine use in BPPV
69:25 How to cure horizontal canal BPPV
71:00 Treatment for vestibular neuritis
72:56 Treatment for Meniere’s disease
74:32 Who benefits from vestibular rehab/exercises
77:23 Dizziness and giddiness
78:15 Take home points
81:06 Outro

Links from the show:

1. The Nine Ways of Working (book) by Michael J. Goldberg
2. aVOR (app) for inner ear disease and physiology by Hamish MacDougall on iTunes
3. Video Link index: NOVEL (Neuro-ophthalmology virtual education library) by Dr. Newman-Toker
4. Overall HINTS findings (videos) with narration for Medscape members from Dr. Newman-Toker
5. HINTS to Diagnose Stroke in the Acute Vestibular Syndrome Three-Step Bedside Oculomotor Examination More Sensitive Than Early MRI Diffusion-Weighted Imaging (video index). Circulation 2009 by Dr. Newman-Toker et al.
6. Does my dizzy patient have a stroke? A systematic review of bedside diagnosis in acute vestibular syndrome. CMAJ 2011 by Dr. Newman-Toker et al
7. The Clinical Differentiation of Cerebellar Infarction from Common Vertigo Syndromes. West J Emerg Med 2009
8. Diagrams of BPPV therapy for horizontal and posterior canals from Neurology 2008
9. HINTS exam explained and demonstrated (YouTube) by Dr. Peter Johns University of Ottawa