how to diagnose dizziness without getting one
TRANSCRIPT
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How to diagnose dizziness
without getting one !
Nassif Mansour
GPwER - SW London
One Day Essential | Neurology Friday 25 January 2019
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• You can actually diagnose dizziness
• How best to manage your patients
• To develop your management pathways
to improve your local service
Objectives
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• 0.5 - 5% of consultations in general
practice
• 20 - 30% of referrals to Neurology
Departments
• Common referral to ENT
• 90% of patients with dizziness have
BPPV, Postural Hypotension or
Vestibular Migraines
Dizziness
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What do they actually mean !
• Vertigo : Illusion of rotation or
movement
• Light headedness, giddiness,
funny turn, disorientation, muzzy head
• Near faint Pre-syncope
What do they actually mean !
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ABC
• Onset
• Pattern
• Duration
• Intensity
• Precipitating / aggravating factors
• Positional / Postural
• Relieving factors
• Associating features
• Poor balance / Falls
• Headaches
• Nausea / Vomiting
• Tinnitus / Hearing loss
• Photo / Phonophobia
ABC
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Symptoms V. Neuritis /
Labyrinthitis
Onset Acute
Intensity
&
Duration
Severe
Days -Wks
Pattern Continuous
Tinnitus Likely
Headache Flu-like
Other Features Disequilibrium
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Symptoms V. Neuritis /
Labyrinthitis
CVA
Onset Acute Acute
Intensity
&
Duration
Severe
Days - Wks
Severe
Days - Wks
Pattern Continuous Continuous
Tinnitus Likely Unlikely
Headache Flu-like 40% of Post. Circulation
CVAs
Other Features Disequilibrium Disequilibrium
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Symptoms V. Neuritis /
Labyrinthitis
CVA Vestibular Migraines
Onset Acute Acute Subacute
Intensity
&
Duration
Severe
Days - Wks
Severe
Days - Wks
Moderate
Hrs - Days
Pattern Continuous Continuous Episodic
Tinnitus Likely Unlikely Less likely
Headache Flu-like 40% of Post.
Circulation CVAs
Common
Other Features Disequilibrium Disequilibrium Migraine related
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Symptoms V. Neuritis /
Labyrinthitis
CVA Vestibular Migraines Meniere’s
Onset Acute Acute Subacute Subacute
Intensity
&
Duration
Severe
Days - Wks
Severe
Days - Wks
Moderate
Hrs - Days
Mod – Severe
Mins to hours
Pattern Continuous Continuous Episodic Episodic
Several a day
Tinnitus Likely Unlikely Less likely Common
Headache Flu-like 40% of Post.
Circulation CVAs
Common Fullness
Other Features Disequilibrium Disequilibrium Migraine related Loss of hearing
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Symptoms V. Neuritis /
Labyrinthitis
CVA Vestibular Migraines Meniere’s BPPV
Onset Acute Acute Subacute Subacute Acute but positional
Intensity
&
Duration
Severe
Days - Wks
Severe
Days - Wks
Moderate
Hrs - Days
Mod – Severe
Mins to hours
Mod – Severe
Secs - Mins
Pattern Continuous Continuous Episodic Episodic
Several a day
Episodic
Several a day
Tinnitus Likely Unlikely Less likely Common Unlikely
Headache Flu-like 40% of Post.
Circulation CVAs
Common Fullness Unlikely
Other Features Disequilibrium Disequilibrium Migraine related Loss of hearing None
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• 20-60% of causes of vertigo
• All ages, peak @ 60
• Vertigo, light-headedness, imbalance, nausea
• Ppt by activities like
Turning in bed
Getting out of bed
Looking sideways
Looking up “top shelf vertigo”
Bending down
• Causes
50% idiopathic
Head injury
Vestibular neuritis / Meniere's
Surgery – dental treatment, Mastoidectomy
Gentamicin toxicity
Benign Paroxysmal Positional Vertigo - BPPV
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• Orthostatic Hypotension
• Cardiac dysrhythmias
• Vaso-vagal
Pre-Syncope
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• Cross-sectional diagnostic study 417
patients ages 65 – 95 yr with dizziness
• Half had more than one cause
• Causes:
• Cardio-Vascular 60%
• Vestibular 15%
• Psychiatric illness 10%
• 25% had medications related side effects
Ann of Fam Med May 1, 2010 vol.8 #3 196-205
Older People & Dizziness
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• Take history (ABC)
• Medications Review
What do you need to do ?
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Meds Dizziness
• Psychotropics
• Antidepressants
• Benzodiazepines
• Pain killers
• Antimuscarinics
• Cardio-vascular
• Diuretics
• Oral Hypoglycaemics
• Anti-epileptics
• PPIs and H2Blockers !
Meds Dizziness
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What do you need to do ?
• Take history (ABC)
• Medications Review
• Check Pulse & BP(sitting & standing after 1-2mins)
• Nystagmus
• Gait
• Positional test
What do you need to do ?
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Dix-Hallpike testDix-Hallpike test
Please Insert Video Here
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Management
• BPPV – Postional Manoeuvre, 80% success rate
• Pre-syncope - ECG and/or 24hr ECG
• Meniere’s disease (actually quite rare);
• Reduce salt, chocolate, red wine
• Bendroflumethiazide 2.5mg
• Betahistine 8-16mg tds (prophylaxis)
• Labyrinthitis/neuritis
• Short term only cinnarizine or prochlorperazine
• Migraine – usual prophylaxis (TCA)
• Refer
• Acute CVA suspected – 999
• If can’t be 100% sure it is not CVA – Stroke/TIA pathway
• Cardio-vascular – Cardiologists
• Migraines – Neurologists
• Not responding, Not sure - Audio-Vestibular
• Chronic Dizziness & Disequilibrium – Physiotherapy
Management
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Epley Manoeuvre Epley Manoeuvre
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In summary
• Dizziness is a non-specific term
• 90% caused by BPPV, Postural Hypotension and Migraines
• Difficult to differentiate between Acute VN and Stroke
• Always consider BPPV but review medications and exclude
cardio-vascular causes in elderly patient with dizziness
• BPPV is the usual cause of recurrent/episodic dizziness, post
head injury, even in those who had labyrinthitis
• 80% of BPPV can be cured in 3 mins
• Vestibular Rehabilitation can restore ADL in 80% of patients
with chronic dizziness
In summary