💡 TLDR Primary Care - Deep Dive (#040)

In This Issue:

✅ Summarized dizziness and vertigo guidelines

🧠 Review the common causes of vertigo

⭐ Physical exams for evaluating vertigo

📈 And more!

💡 Deep Dive: Dizziness and Vertigo

In-depth review of key recent guidelines

This week, we’ll review the latest clinical guidelines on Dizziness and Vertigo. To ensure accurate diagnosis and effective management, it is crucial to comprehend the underlying causes of dizziness and vertigo. A symptom of vestibular dysfunction, dizziness and vertigo manifest as a sensation of motion, often characterized by rotational movement. These symptoms can arise from diverse factors, including inner ear disorders, specific medications, neurological conditions, and cardiovascular issues. The identification of the root cause is essential for the development of targeted treatment strategies.

Dizziness, including vertigo, affects a substantial proportion of adults annually, ranging from 15% to over 20%. Dizziness is a broad term used to describe a weak, unsteady, or spinning feeling. It is essential to distinguish between lightheadedness or weakness (such as presyncope or syncope) and peripheral versus central causes of vertigo.

We made this helpful graphic to highlight the different causes of dizziness:

Guidelines on the evaluation and management of dizziness and vertigo are published by the European Society for Vascular Surgery (2023), the Society for Academic Emergency Medicine (2023), and the American Physical Therapy Association (2022), among others.

For a full review of dizziness and vertigo guidelines, head over to Pathway. We’ll cover some key takeaways below (with the recommendation strength in parentheses). 

1. Diagnostic investigations:

• Obtain routine three-component head impulse-nystagmus-test of skew examination by trained clinicians trained to distinguish between central (stroke) and peripheral (inner ear) diagnoses in adult patients with acute vestibular syndrome with nystagmus presenting to the emergency department. (A)
• Consider obtaining a hearing assessment at the bedside by finger rub to identify new unilateral hearing loss as an additional criterion to aid in identifying stroke, even if the head impulse-nystagmus-test of skew examination result suggests a peripheral vestibular diagnosis. (C)
• Perform the Dix-Hallpike maneuver to diagnose BPPV in adult patients with transient episodic vestibular syndrome (see below for maneuver instructions). Look to elicit provoked vertigo associated with torsional, upbeating nystagmus. Repeat the maneuver with the opposite ear down if the initial maneuver is negative. (B)
• Do not obtain routine vestibular testing in patients meeting diagnostic criteria for BPPV without additional vestibular signs or symptoms. (D)
• Obtain cervical vascular imaging to identify disruption of blood flow during head-turning to diagnose vertebrobasilar ischemia in patients with vertigo or dizziness on head-turning. (B)
• Obtain a supine roll test to assess for lateral semicircular canal BPPV in patients with a history compatible with BPPV and horizontal or no nystagmus during the Dix-Hallpike maneuver. (B)
• Clinicians should obtain an audiogram when assessing a patient for the diagnosis of Ménière’s disease. (B)
• Diagnose definite or probable Ménière’s disease in patients presenting with > 2 episodes of vertigo lasting 20 minutes to 12 hours (definite) or up to 24 hours (probable) AND sensorineural hearing loss, tinnitus, or pressure in the affected ear. (B)
• Consider obtaining MRI of the internal auditory canal and posterior fossa in patients with possible Ménière’s disease and audiometrically verified asymmetric sensorineural hearing loss. (C)

⭐ Check out these helpful calculators for assessing vertigo

HINTS Exam: Evaluate for stroke in acute vestibular syndrome

ICVD Criteria: Evaluate for Ménière's disease

2. Differential Diagnosis:

Peripheral Vertigo

• Benign Paroxysmal Positional Vertigo
  • Brief recurrent episodes of vertigo triggered by specific head movements.
  • Episodes last for seconds to minutes.
  • Caused by dislodged calcium crystals in the inner ear.
• Vestibular Neuritis
  • Inflammation of the vestibular nerve.
  • Episodes last for hours to days.
  • Sudden severe vertigo, nausea, vomiting, and balance difficulties.
  • Hearing is typically unaffected.
• Ménière's Disease
  • Chronic condition of the inner ear.
  • Episodes last for minutes to hours.
  • Recurring episodes of vertigo, fluctuating hearing loss, tinnitus, and ear fullness.
• Labyrinthitis
  • Inner ear inflammation commonly caused by viral or bacterial infection.
  • Sudden onset of vertigo, hearing loss, tinnitus, and sometimes nausea/vomiting.

Central Vertigo

• Stroke
  • Disruption of or abnormal delivery of blood supply to the brain, causing brain damage.
  • Symptoms vary but can include sudden dizziness, balance problems, and difficulty speaking/understanding.
• Meningitis
  • Infection causing inflammation of the protective membranes surrounding the brain and spinal cord.
  • Symptoms include severe headache, neck stiffness, fever, confusion, sensitivity to light, and possible dizziness/vertigo.
• Migraine
  • Recurrent moderate to severe headaches.
  • Can be accompanied by sensitivity to light/sound, nausea, and dizziness.
  • Vestibular migraines can feature prominent dizziness/vertigo (can be a peripheral cause of vertigo).
• Multiple Sclerosis
  • Chronic autoimmune disease affecting the central nervous system.
  • Dizziness and vertigo can be symptoms, along with fatigue, muscle weakness, and coordination difficulties.

3. Physical Exam:

Dix-Hallpike Test: 

• With the patient sitting on the exam table, the physician turns the patient's head 45 degrees in one direction. 
• Then, supporting the patient's head, move from upright to supine, ending with the head extended 20 degrees off the end of the exam table. Remain for 30 seconds. 
• Then return to upright for 30 seconds. Repeat for the opposite side. 
• This test is positive if this maneuver triggers vertigo with nystagmus.

Image Credit

Epley Maneuver: 

• Have the patient sit on the exam table with eyes open and the head turned 45 degrees to the affected side. 
• Guide their head as the patient goes from upright to supine ending with the head extended 20 degrees off the exam table. 
• Turn the patient’s head 90 degrees to the opposite side and have them remain for 30 seconds. Then turn the head an additional 90 degrees to that side while the patient rotates their body 90 degrees in the same direction and remains for 30 seconds. 
• Then the patient sits up on the other side of the exam table.

Image Credit

HINTS Exam: This includes the Head-Impulse, Nystagmus, and Test of Skew. 

• For head-impulse, the patient is seated, and the head is moved 10 degrees to the right and left while having their eyes fixed on the physician's nose. Look for saccades to demonstrate a peripheral etiology. Nystagmus can also be observed, which involves a rhythmic oscillation of the eyes. 
• Test of Skew starts with the patient looking ahead and then covering and uncovering each eye. Look for vertical deviation of the covered eye after uncovering to demonstrate a central pathology. 

4. Management:

Benign Paroxysmal Positional Vertigo:

• Perform the Epley canalith repositioning maneuver at the time of diagnosis in adult patients with BPPV diagnosed by a positive Dix-Hallpike test. (B)
• Assess patients with BPPV for factors modifying management, including impaired mobility or balance, CNS disorders, a lack of home support, or increased risk of falling. (B)
• Do not use vestibular suppressant medications (such as antihistamines or benzodiazepines) routinely in patients with BPPV. (D)
• Reassess patients within one month after an initial period of observation or treatment to document the resolution or persistence of symptoms. (B)
• Evaluate patients with persistent symptoms for unresolved BPPV versus underlying peripheral vestibular or CNS disorders. (B)

Vestibular Neuritis:

• Consider ensuring shared decision-making with patients to weigh the risks and benefits of short-term corticosteroid treatment in adult patients with a clinical diagnosis of vestibular neuritis presenting within three days of onset. (C)

Ménière's Disease:

• Offer a limited course of vestibular suppressants (such as antihistamines or benzodiazepines) for the management of acute vertigo attacks in patients with Ménière's Disease. (B)
• Consider offering diuretics (such as hydrochlorothiazide 25mg once daily) or betahistine (such as 8-16 mg 1-3 times a day) for maintenance therapy to reduce symptoms or prevent attacks. (C)
• Consider offering routine thiazide diuretics. (E)
• Offer vestibular rehabilitation and physical therapy. (A)
• Consider referring to a clinician who can perform intratympanic gentamicin injections in patients not responsive to non-ablative treatment. (B)
• Counsel patients with Ménière's Disease and hearing loss on the use of amplification and hearing assistive technology. (B)
• Do not use positive pressure therapy in patients with Ménière's Disease. (D)

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