Dizziness:

Diagnosis &
Management
Our discussion today

• What is Dizziness ?

• Why is it important ?

• What is the best approach to diagnosis ?

• What is the best way to manage the patient?

• Does the patient need further investigation?

 Your patient presents with…..
• A 60 year old woman reports sudden
dizziness when she arises from bed.
• She was nauseous and had been
vomiting.
• She recently had a severe cold.
• She complained of dizziness on turning
her head to the right.
• She was frightened to leave her house.
• A 30 year old complained of dizziness
for a few weeks.
• Dizziness was noted when turning in
bed more to the right than to the left
• The patient felt dizzy when placing
clothes on a clothesline
• Severe vertigo occurred with nausea
and vomiting
• No other history of complaints
 Our discussion today

What is Dizziness ?

‘the sensation of motion

when no motion is occurring relative to earth’s gravity’.

Thomas JV, Vertigo: An Overview, Page 1-7 Indian Academy of Neurology, Guidelines on vertigo
 It has a profound effect on daily functioning

Dizziness of vestibular origin

Impact on daily functioning 1
80%
70%
70%
60%
50%
41% 40%
40%
30%
20%
10%
0%
Seek medical help Unable to work Not able to perform
daily activities
Dizziness of vestibular origin

Recurrence occurs in Affects daily lives, leads Reduced QoL

88% 2 to sick leave2 Psychiatric problems2

1. Neuhauser, HK Arch Intern Med. 2008;168(19):2118-2124

2. Thomas JV, Vertigo: An Overview, Page 1-7 Indian Academy of Neurology, Guidelines on vertigo
 Misdiagnosis is common

• Misdiagnosis rates of peripheral Proportion of patients misdiagnosed

vestibular disorders : 74% to 81%1

• Benign paroxysmal positional vertigo

(BPPV) and vestibular neuritis are
frequently confused for one another 1 Upto 80%
misdiagnosed
• Peripheral neuritis is confused with
more serious disorders such as
Misdiagnosis Correct diagnosis
stroke1

Royl G et al Eur Neurol 2011;66:256–263

Our discussion today

What is the best approach to diagnose ?

 It’s a constellation of different feelings
with varying expressions

“about to “unsteady
faint or ‘fall on my feet”
out’

“dizzy”

“spinning
or vertigo”
“light-
headed” disoriented
or
confused.”

The answers are often inconsistent or describe more than 1 type of sensation
Patient’s intelligence Patient’s education Nuances of language Age

Practical management of the Dizzy Patient, Ed.Goebel JA Lippincott, Williams and Wilkins
 Key spell characteristics for assessment

About the dizzy Sensation

spell –”description” Vertigo, Imbalance, Oscillopsia, Syncope,
Initial spell
presyncope

Last spell Date, how long it lasted, nature of the spell

Duration/Frequency
Frequency of spells Times per day/week or month

Duration of spells Seconds. Seconds to a few minutes, minutes,

hours, hours to days
What caused it ?
Precipitating factors Causal event, position change, exertion,
medication
Which are the Associated Nausea, vomiting, hearing loss, aural fullness,
systems involved symptoms tinnitus, weakness, paresthesias,
–auditory, ocular etc. lightheadedness or syncope, headaches

Practical management of the Dizzy Patient, Ed.Goebel JA Lippincott, Williams and Wilkins
 Revisiting the presenting symptoms –
What do they mean ?

Does the room Do you feel Do you feel like Do you feel light
spin around unsteady? you may faint ? headed ?

VERTIGO . DYSEQUILIBRIUM PRESYNCOPE PANIC ATTACKS

HYPERVENTILATION

Peripheral
neuropathy
+ Nausea and
eye disease, Cardiovascular
vomiting disorders
= peripheral cause peripheral
vestibular
disorders.

Kanaglingam, J BMJ. 2005 Mar 5; 330(7490): 523.

 Asking the right questions

1. Onset, time course, and length of the attacks

2. Does head motion incite or aggravate the vertigo?
3. Is there hearing loss, tinnitus, or a sensation of aural fullness?
4. Are these exaggerated when the dizziness is worse?
5. Any previous head injury, pressure change, or symptoms of a viral syndrome ?
6. Is it associated with headache?
7. Are there any neurological symptoms?
8. Is there any history of drug?
9. Is there history of any psychiatric illness?

Kanikanna MA, Kandadai RM, Jabeen SA, Guidelines on Vertigo, Indian Academy of Neurology, pg 21-28
 A lookout for associated symptoms

• Tinnitus • Headache/migraine • Anxiety

Neurologic
Otologic

Psychiatric
• Hearing loss • Paralysis, numbness • Pallor,
• Fullness • Visual disturbance sweating
• Otalgia • Tremors • Depression
• Seizure • Restlessness
• Dysphagia • Irritability
• Concentration
• Loss of
consciousness
• Facial palsy

Nausea and vomiting may occur with moderate to severe episodes

Practical management of the Dizzy Patient, Ed.Goebel JA Lippincott, Williams and Wilkins
 Most common causes of vertigo
Nausea/ Previous
Condition Description Time course Tinnitus Hearing
Vomiting history

Benign Resolves over

Vertigo associated with There may be
paroxysmal days but is
head turning or rolling over Yes a history of None Not affected
positional followed by
in bed. head injury
vertigo dysequilibrium.

Attacks last Hearing loss

Triad of vertigo, tinnitus, from 1 to 24 Present; comes and
Meniere's and hearing loss, often hours but are often goes at first
disease associated with a pressure often followed worsens over but is
sensation in affected ear. by persistent time eventually
dysequilibrium permanent

Recurrent vertigo attacks

Vestibular lasting hours or days.
A preceding
neuritis (often Followed by
viral illness is None Not affected
misdiagnosed dysequilibrium, while
common
as labyrinthitis) central compensation
occurs.

Kanaglingam, J BMJ. 2005 Mar 5; 330(7490): 523.

 Simple tests for assessment Neuro-otologic
examination - Nystagmus
• Involuntary movement of the eyes - Eyes drift unintentionally
• Caused by disorder causing a malfunction of VOR
• Gaze stabilization not working
• Characteristics of nystagmus are clues to site of underlying disorder

Normal nystagmus Abnormal nystagmus

e.g. when tracking a Eyes should be still, but they are in motion e.g vertigo
visual pattern.

Jerk nystagmus /Vestibular nystagmus

Characterised by a slow drift of the eyes in one direction followed
by a compensatory fast jerk of the eyes in the opposite direction
Pendular nystagmus –Not vestibular in nature but ocular in nature
Characterised by eyes moving slowly and smoothlybut repeatedly
from side to side without a jerk component

Practical management of the Dizzy Patient, Ed.Goebel JA Lippincott, Williams and Wilkins
 Directions of nystagmus

Peripheral Vestibular Central vestibular

Effect of Nystagmus decreases Nystagmus does not

fixation change or increases
Direction of Usually mixed plan Usually single plane
nystagmus (horizontal/torsional) (Horizontal, torsional
or vertical)

Effect of gaze Nystagmus increases Nystagmus does not

with gaze toward change or reverses
direction of quick phase direction

Neurologic clinics –Otoneurology, Ed Furman, JM and Whitney SL , Aug 2005, 23 (3) , p683
The Standing test

• Patient is asked to stand with eyes open, feet close together

• Then stand on one leg with eyes closed.

• Stands for about 15 -20 seconds on the left leg followed by 15-20
seconds on the right leg

Look for swaying of the body

DIAGNOSIS - Acute peripheral vestibular lesion IF

‘discus thrower’s position’
1. The head turns to the side of the lesion.
2. Trunk twisted to the side of the lesion.
3. Deviation of both arms on that side.
4. Raising of the hand on the healthy side.
5. Lowering of the hand on the side of the lesion with a tendency of falling towards the
side of the lesion.
 Differentiating Central or peripheral
Test Peripheral Central (brainstem or
(labyrinth) cerebellum)
Direction of associated Unidirectional; fast Bidirectional or
nystagmus phase opposite unidirectional
lesion
Purely horizontal nystagmus Uncommon Common
without torsional component

Vertical or purely torsional Never present May be present

nystagmus
Visual fixation Inhibits nystagmus No inhibition
and vertigo
Severity of vertigo Marked Often mild
Direction of spin Toward fast phase Variable
Direction of fall Toward slow phase Variable

Kothari S, Guidelines on Vertigo, Indian Academy of Neurology

Differentiating Central or peripheral

Test Peripheral (labyrinth) Central (brainstem or

cerebellum)
Duration of Finite (minutes, days, May be chronic
symptoms weeks) but recurrent
Tinnitus and/or Often present Usually absent
deafness
Associated CNS None Extremely common
abnormalities (e.g., diplopia, hiccups, cranial
neuropathies, dysarthria)
Common causes BPPV, infection Vascular, demyelinating,
(labyrinthitis), Ménière’s, neoplasm
neuronitis, ischemia,
trauma, toxin

Kothari S, Guidelines on Vertigo, Indian Academy of Neurology

 Red Flags to look out for

Red flag” symptoms should alert you to a non-

vestibular cause:
• Persistent, worsening vertigo or disequilibrium
• Atypical “non-peripheral” vertigo, such as vertical movement
• Severe headache, especially early in the morning
• Diplopia
• Cranial nerve palsies
• Dysarthria
• Ataxia, or other cerebellar signs
• Papilloedema

Kanaglingam, J BMJ. 2005 Mar 5; 330(7490): 523

 Patient presents with dizziness

History
(Medication ? caffeine, nicotine, and alcohol intake? head trauma or injury)

False sense of motion of

spinning sensation

Headache and other Vertigo Neurological deficit

symptoms s/o migraine

CNS causes Other causes:

Migraine Hearing loss traumatic, cervicogenic

Neuro-imaging
Yes No

Fever: Vestibular neuritis: BPPV

No fever:
labyrinthitis viral infection
Ménière’s
Disease
Perform Dix-Hallpike
1. Kanikanna MA, Kandadai RM, Jabeen SA, Guidelines on Vertigo, Indian Academy of Neurology
Our discussion today

What is the best way to manage the patient?

Does the patient need further investigation?

Your goal

• Provide relief from symptoms

• Reduce the chances of recurrence

• Reduce the severity of a recurrent attack

• Does the patient need to be investigated further ?

Start with

Empathy and Vestibular

Pharmacotherapy
reassurance rehabilitation

• Anxiety co-occurs with vertigo

• Positive counselling

• Pharmacotherapy for rapid relief from symptoms to reinforce confidence

• Counselling on vestibular rehabilitation exercises

Kirtane MV, Biswas A, Guidelines on Vertigo, Indian Academy of Neurology

 Onset of action of commonly used agents
Agent Onset of action

1
Prochlorperazine IM: 10 to 20 minutes; Oral: 30 to 40 minutes

The peak plasma levels of cinnarizine are obtained

2
1 to 3 hours after intake.
Cinnarizine
The onset of action may therefore take a few hours

The onset of effect varies between a few days and

weeks. Improvement of symptoms may take
Beta histine
up to two weeks and that best results are sometimes
3,4
obtained only after a few months.

1. https://www.drugs.com/ppa/prochlorperazine.html, Accessed 24 May, 2017

2. http://home.intekom.com/pharm/janssen/stugeron.html, Accessed 24 May, 2017
3. http://meppo.com/pdf/drugs/239-BETASERC-1415103021.pdf
4. http://vardgivarwebb.regionostergotland.se/pages/233476/betaserc%202003.pdf
 Management • Explanation and reassurance are
important, as anxiety exacerbates
vertigo.
• Prochlorperazine to relieve symptoms.
• Mouth dissolving tablets may act fast
• Balance rehabilitation is important
especially in the elderly

• A 60 year old woman reports sudden • Refer her to an ENT if

dizziness when she arises from bed. • She has hearing loss
• She feels nauseous and had been or
vomiting.
• Recurrent or persistent vertigo with
• She recently had a severe cold. peripheral vestibular
• She is dizzy on turning her head to characteristics
the right. or
• She is frightened to leave her house. • If otoscopy findings are abnormal.

Kanagalingam, BMJ. 2005 Mar 5; 330(7490): 523

 Prochlorperazine – for relief of symptoms
in acute vertigo
• The best drug for symptomatic relief is prochlorperazine1

• Anticholinergic and antidopaminergic effects

• Symptom relief seen within a week

 Relieves the patient from the very debilitating rotating/spinning sensation

 Preferred for relief of co-symptoms of nausea and anxiety

• Shows significant benefits in preventing a recurrence of all symptoms 2

• Lower incidence of drowsiness compared to cinnarizine2

• Recommended by guidelines3

• As a ‘vestibular sedative’ prochlorperazine relieves symptoms of dizziness originating

from the vestibular labyrinthine system (inner ear) such as those due to labyrinthitis,
Meniere’s syndrome

1. Biswas, A VERTIGO - and what is New in it from the General Physician’s Perspective
2. Kameswaran M et al. Int J Otorhinolaryngol Head Neck Surg. 2017 Apr;3(2):404-413
3. Kirtane, MV Management of Vertigo, Guidelines
Prochlorperazine alone may be enough
Combinations may increase risk of side effects

Cinnarizine Dymenhydrinate Domperidone

Drowsiness or dizziness Restlessness,

Drowsiness, excitation, nervousness, or insomnia;
sleepiness, and blurred or double vision; dry mouth, nose, Co-prescribing may increase
lassitude and postural the arrhythmogenic potential
or throat; decreased appetite, nausea,
instability frequently especially in elderly5
seen 1,2, 3 vomiting, or diarrhea; difficulty urinating;
or an irregular or fast heartbeat.4

Chronic use of domperidone

may, induce neuropsychiatric
syndromes similar to those
seen with the use of
antipsychotics.. 6

1. Singh AK1, Chaturvedi VN. Indian J Otolaryngol Head Neck Surg. 1998 Oct;50(4):392-7.
2. Deering RB, Prescott P Curr Med Res Opin. 1986;10(4):209-14.
3. Lucertini M1, Mirante N. 2007 May 16;91(1):180-90. Epub 2007 Mar 2.
4. http://www.emedicinehealth.com/drug-dimenhydrinate/article_em.htm#sideeffects,
5. Rojas-Fernandez C Canada. Drugs Aging. 2014 Nov;31(11):805-13
6. Roy-Desruisseaux J1,. Ann Pharmacother. 2011 Sep;45(9):e51
7. Hondeghem LM1 Acta Cardiol. 2011 Aug;66(4):421-5.
Betahistine in long standing vertigo

• Betahistine is currently used in the management of vertigo and vestibular pathologies

with different aetiologies

• Betahistine efficacy can be explained by mechanisms targeting the histamine receptors

(HRs) at three different levels:

• the vascular tree, with an increase of cochlear and vestibular blood flow involving
the H1R;
• the central nervous system, with an increase of histamine turnover implicating the
H3R, and
• the peripheral labyrinth, with a decrease of vestibular input implying the H3R/H4R

• Clinical data from vestibular loss patients show the impact of betahistine treatment for
• the long-term control of vertigo
• improvement of balance and quality of life

• The psychomotor effects of betahistine could not be distinguished from those of placebo

J Vestib Res. 2013;23(3):139-51

Br J Clin Pharmacol. 1991 Oct;32(4):455-8.
 Recent evidences - 2017 registry on Vertigo
• Prochlorperazine amongst the • Recurrence rate least with
most preferred drugs prochlorperazine and highest
with cinnarizine

30 60

24.8 51.5
25 50
Patient preference (%)

20 40

Axis Title (%)

15 13.4 29
30

10 20

5 10

0 0
Prochlorperazine Cinnarizine
Prochlorperazine Cinnarizine

1. ASEAN Academy of Neuro-Otology & Audiology Congress, 19-20 Nov, 2016;

 Weighing the benefits with the risk of EPS
In comparative studies (with cinnarizine) none of the patients developed prochloperazine
induced synkinesia or basal ganglion toxicity

Extrapyramidal Side effects of Prochlorperazine

Drug-induced acute dystonic reactions (EPS) occur in 0.5% to 1% of patients
given metoclopramide or prochlorperazine. – Australian Prescriber 2001

“Extrapyramidal reactions may occur in less than 1% of patients receiving

prochlorperazine” – Drugs.com

“Certain patient groups have increased susceptibility to these extrapyramidal reactions” - Rodgers C.
.

Extrapyramidal side effects of antiemetics presenting as psychiatric illness Gen Hosp Psychiatry. 1992 May;14(3):192-5.
Summary
• Vertigo can occur due to a peripheral or central causes

• A good history and simple tests can help to reach a diagnosis in majority of cases

• Vestibular causes are the most common causes of vertigo

• The first step to management is to relieve the symptoms of vertigo and associated
symptoms of anxiety/nausea and vomiting

• Prochlorperazine is the appropriate choice for rapid relief from symptoms of vertigo
and associated symptoms of nausea and vomiting

• Given as a short course of upto 7 days, prochlorperazine (as a mouth dissolving

tablet) is effective in relief of symptoms and return to normal life

• Seven day therapy reduces the recurrence

• In the event of recurrence or diagnosis suggestive of central cause, an immediate

referral is recommended