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Dizziness & Vertigo

4 min read

DIZZINESS & VERTIGO IN PRIMARY CARE

Dizziness COMB

Objectives

  1. Explain the patho-physiology of human balance system
  2. Compare and contrast dizziness and vertigo
  3. Recognize the common causes of dizziness / vertigo
  4. Take an adequate history from a dizzy patient
  5. Perform Hallpike and Epley’s manoeuvres on a dizzy patient
  6. Identify the RED flag and ask for appropriate lab investigation in a dizzy patient
  7. Justify the differential diagnosis of dizziness
  8. Discuss the available therapeutic options at primary care level and criteria for referral to the secondary care

Definitions

Incidence/Prevalence

  • Studies into dizziness indicated that around 30% of patients were found to have vertigo, rising to 56.4% in an older population.
  • A GP can therefore expect between 10-20 patients with vertigo in one year.
  • 93% of primary care patients with vertigo have either benign paroxysmal positional vertigo (BPPV), acute vestibular neuritis, or Ménière’s disease.

Common Causes in General Practice

  • 80%: Vestibular Neuritis or BPV
  • 15%: Meniere’s disease or Vertebrobasilar insufficiency
  • 3%: Transient Ischemic Attack (TIA)
  • 1%: Ear Infections
  • 1%: Other causes, including Multiple sclerosis, Psychological causes e.g. Anxiety

Timing of Symptoms Z

  • The duration of vertigo episodes and associated auditory symptoms will help to narrow the differential diagnosis.

Primary Care Guidelines – Vertigo/Dizziness

  • Vertigo is defined as an illusion of movement.
  • Explore characteristics of symptoms; examine for nystagmus.
  • Do a Hallpike test in all patients presenting with vertigo/dizziness.
  • At every stage, explore ‘red flags’ and refer as necessary.
  • Dizziness with presyncopal symptoms should be referred to cardiology.
  • Exclude orthostatic/Postural hypotension.
  • Consider migraine & treat if appropriate.

Presentations

1. Vestibular Neuritis

2. Benign Paroxysmal Positional Vertigo (BPPV)

3. Meniere’s Disease

Examinations

Case Dizziness

RED FLAGS

  • First attack of vertigo with acute severe headache (REFER TO A/E – R/O CVA)
  • Persistent symptoms for > 1 month (REFER TO ENT)
  • Nystagmus lasting > 48 hours (REFER TO ENT)
  • Unilateral tinnitus/dyacusis/aural fullness
  • Sudden/fluctuating hearing loss
  • Dysconjugate eye movements
  • Posterior circulation symptoms
  • Positive Hallpike test, provoking nystagmus but no symptoms
  • Vertical nystagmus &
  • Cerebellar signs

(All these refer to neurology).

Important Points in the History

  • Onset - specific provoking events such as flying or trauma.
  • Duration:
    • Seconds - benign positional vertigo
    • Hours - Meniere’s disease
    • Weeks - labyrinthitis, post-head trauma, vestibular neuritis
    • Years - may be psychogenic
  • Associated auditory symptoms - rare in primary CNS lesion.
  • Other associated symptoms:
    • Nausea and vomiting in a vestibular cause.
    • Neurological symptoms such as visual disturbance, dysarthria in a central lesion.

Preventive Measures for Recurrent Attacks

  • Restrict salt and fluid intake.
  • Stop smoking and restrict excess coffee or alcohol.
  • Betahistine hydrochloride 16mg regularly TDS seems most effective in Meniere’s.
  • Cinnarizine 15-30 mg TDS.

Points to Consider

  • Warn patients when drugs may sedate.
  • Prochlorperazine is less sedating than some other recommended antihistamines but may cause a dystonic reaction (particularly in children and young women).
  • Benzodiazepines are not recommended.

Recurrent Vertigo

  • The most important first step in the management of recurrent vertigo is to distinguish vertigo from dizziness.
  • In attacks of vertigo, there is a sense of mobile disequilibrium (“the room spinning”) which, if severe, results in uncontrolled staggering in one direction, which may be only prevented by grabbing a solid object.

Referral to Secondary Care

  • Recurrent episodes
  • Neurological symptoms (e.g., dysphasia, paraesthesia, or weakness)
  • Associated sensorineural deafness
  • Inadequate visualization of the entire tympanic membrane or an abnormality (e.g., Cholesteatoma)
  • Atypical nystagmus (e.g., Non-horizontal, persisting for weeks, changing in direction or differing in each eye)

Referral Guidelines

  • If the patient has hearing problems in addition to vertigo, then referral should be made to an ENT specialist. Other cases should be referred to a neurologist.

While Awaiting Referral

  • Consider symptomatic drug treatment for no longer than 1 week because prolonged use may delay vestibular compensation.
  • It is important that the person stops symptomatic treatment 48 hours before seeing a specialist, as it will interfere with diagnostic tests such as the Dix-Hallpike manoeuvre.

References

  1. Clinical practice guideline: BPPV
  2. Vertigo - diagnosis and management in primary care: BJMP – 2009
  3. Dizziness primary care management guidelines for GPs. 24 June 2016

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