Dizziness

Question 1

Dizziness

Answer 1

Question 2

Dizziness Red Flags

Answer 2

Question 3

Benign Paroxysmal Positional Vertigo (BPPV)

Answer 3

Vertigo - False sense of motion
Pathophysiology - loose otolith in semicircular canals causing a false sense of motion.
Identifier - positive findings with Dix-Hallpike maneuver, episodic vertigo without hearing loss
Treatment - Epley Maneuver

Question 4

Meniere’s Disease

Answer 4

Vertigo - False sense of motion
Pathophysiology - increased endolymphatic fluid in the inner ear
Identifier- episodic vertigo with hearing loss in affected ear.
Treatment
Bed rest and reassurance in acute attack
Antihistamine (cinnarizine) is useful if prolonged or buccal prochlorperazine if severe for up to 7 days.

Question 5

Vestibular Neuritis/Labyrinthitis

Answer 5

Vertigo - False sense of motion

Pathophysiology - Postulated to be a viral or post-viral inflammatory disorder affecting the vestibular portion of the eighth cranial nerve. This may lead to potential atrophy of the vestibular nerve.

Identifier - Vertigo is most severe for the first 1 to 2 days, and then gradually improves over several weeks.

Treatment
Bed rest & hydration
Benzodiazepines, cinnarizine, prochlorperazine.
Oral corticosteroids.

Question 6

Vestibular Migraine

Answer 6

Vertigo - False sense of motion

Pathophysiology - uncertain, one hypothesis is that trigeminal nuclei stimulation causes nystagmus in persons with migraine

Identifier- episodic vertigo with signs of migraines, plus photophobia, phonophobia, or aura during at least 2 episodes of vertigo

Treatment
Vestibular physical therapy. It is tailored to each patient based on vestibular testing. It can include balance exercises, gaze stability training and exercises to help with desensitization of triggers.

Abortive medications
NSAID or acetaminophen
Dihydroergotamine DHE (5-HT1 receptor agonist)
Sumatriptans are more selective than DHE for the 5-HT receptors.

Prophylactic medications
Propranolol
Amitriptyline
Verapamil
Valproate acid

Question 7

Orthostatic Hypotension

Answer 7

Presyncope - Feeling of losing consciousness or blacking out

Pathophysiology - drop in blood pressure on position change causing decreased blood flow to the brain

Identifier- systolic blood pressure decrease of 20mmHg, diastolic blood pressure decreases of 10mmHg or a pulse increase of 30bmp

Treatment
Non-drug therapy includes replacement of fluids, rising slowly from lying or sitting positions, sleeping with the head of the bed elevated, increasing salt intake, regular exercise and review medication regimen.

Fludrocortisone
first line treatment mineralocorticoid.
Adverse effects - Hypokalemia, headaches and CCF.

Midodrine
Peripheral Alpha 1 agonist
Adverse effects - pruritis and paresthesia.
Not to be taken after 6pm