Common Neurological Presentations: Dizziness

Question 1

Key questions to ask to establish timings

Answer 1

Before attack

• what were you doing
• any possible triggers? => recent resp infection

During

• acute/gradual onset
• progression and duration
• intermittent/continuous
• other symptoms - hearing loss, N+V?

After
-able to return to normal?

Frequency of attacks

Question 2

Key questions in systemic review

Answer 2

General - fever => inflammatory?
-facial rash - Ramsay Hunt?

Neuro - N+V, imbalance or falls?

• seizures, falls, LOC, headaches
• vision, hearing, photophobia
• motor/sensory limb weakness
• bowels and bladder

Cardioresp
-chest pain, palpitations, SOB
-wheeze, cough (productive and contents?)
-leg swelling
CV RISK FACTORS

ANY RECENT HEAD TRAUMA?

Question 3

Difference between

• vertigo
• dizziness
• lightheaded

Answer 3

Vertigo - the room seems to be spinning when it is not

Dizziness - unsteady on feet

Lightheaded - feelings faint

Question 4

BPPV

• risk factors
• core features
• investigations
• management

Answer 4

Risk factors
-older age

Core features
Triggered by head turning, often lying down
Episodes - 30s

Diagnosis - DixHallpike
-aim to recreate symptoms

Managment - Epley => move otoliths out of semicircular canals

Question 5

Vestibular neuritis vs labyrinthitis

• risk factors
• core features
• investigations
• management

Answer 5

Main difference

• labyrinthitis - hearing loss
• vestibular neuritis - no hearing loss

Risk factors
-preceded by URTI

Core features
Sudden, intense onset vertigo, N+V, lasts DAYS

Investigation

• HINTS => peripheral or central causes
• hearing test

Management

• short term antiemetics
• vestibular rehabilitation, encourage gentle movement

Question 6

Meniere’s disease

• risk factors
• core features
• investigations
• management

Answer 6

Risk factors
-older age females

Core features
VERTIGO + TINNITUS + HEARING LOSS

Lasts MINUTES - HOURS

Clusters of attacks

N+V

Diagnosis - ENT referral

Management
Symptomatic (dizzy, N+V) - prochloperazine
Prevention - betahistine

Question 7

Possible peripheral and central causes

-when would you suspect central or peripheral cause

Answer 7

Peripheral

• BPPV
• Menieres
• Labyrinthitis
• Vestibular neuritis

Central

• Brainstem stroke?
• Neuro cond - MS, epilepsy, brain tumour, migraine
• Head injury

Presents with vertigo AND other neuro symptoms
-weakness/tingling, slurred speech, ataxia, confusion

Question 8

PMHx, DHx, allergies

Answer 8

PMHx
-cardiovascular disease

DHx
-medications that may cause vertigo - aminoglycosides, alcohol, aspirin, diuretics

FHx - CV, MS disease

Question 9

SHx

Answer 9

Impact of symptoms

• support at home - partner, children, carer?
• dependents at home

Work

• finances
• commute to work => driving?
• advise them to inform DVLA especially if attacks are unpredictable

Substances
-alcohol, smoking, recdrugs => can worsen symptoms