Dizziness — Definition and Treatment

Image: “forest-1366345_640” by Felix_Hu
License: CC0 1.0

Definition of Dizziness

Dizziness is a common term used for various feelings or sensations, which include vertigo, disequilibrium and presyncope that occur from various kinds of vestibular and non-vestibular causes.

Epidemiology of Dizziness

• According to studies, prevalence of vertigo is the highest followed by unsteadiness and dizziness.
• The incidence of imbalance, dizziness and vertigo is around 5–10% and increases to 40% in older people with more than 40 years of age.
• Reports show an estimated number of 3.9 million ED visits due to dizziness and vertigo in US.
• Dizziness is the 9th common clinical symptom observed in all patients. However, this is reported as the third common symptom in elder patients in the age of 65–75 years. The presence of this symptom in elder patients also increase the chances of falls leading to accidental deaths.

Differential diagnosis of Dizziness

Diagnosis of dizziness can be a daunting task for the physician’s due to its non-specific and varied aetiologies. The differential diagnosis associated with dizziness is broad and accounts only for 10% representation of the common aetiologies. However, physical examination and correct patient history can support the differential diagnosis. Patient history and right understanding of the causes is important for classifying dizziness into one of the types and treatment plan.

The four main types

1. Disequilibrium
2. Vertigo
3. Light-headedness
4. Presyncope

Vertigo

Vertigo is the most common cause of dizziness that includes

1. Vestibular neuritis
2. Benign paroxysmal positional vertigo
3. Labyrinthitis
4. Meniere disease

Duration of the symptoms and hearing loss are important for differential diagnosis. Disequilibrium or sense of imbalance can be caused by various underlying conditions like stroke and neurological findings. Light-headedness is often associated with psychiatric issues like anxiety and depression.

Various types and differential diagnosis for dizziness

• Acute and prolonged dizziness is caused due to neurological issues like cerebellar or brainstem stroke.
• Patients with peripheral vestibular lesion display unidirectional horizontal spontaneous nystagmus.
• Transient ischemic attacks display dizziness as its only symptom. However, recurrent episodes can also be associated with neurological disorders.
• Meniere disease is also characterized by repeated episodes of dizziness which are associated with auditory symptoms, ear fullness, hearing loss or tinnitus.
• Repeated spontaneous dizziness without an associated with neurological or auditory symptoms are often associated with migraines.
• Repeated episodes of dizziness triggered by position is its most common cause known like BPPV and orthostatic hypotension. Various positional changes like rolling over the bed, lying down, looking up or reaching onto something can trigger BPPV. In contrast to this, getting up from seated position or from lying position can trigger orthostatic hypotension.
• Chronic repeated episodes of dizziness are also associated with anxiety disorders.

Clinical features and presentations of Dizziness

Various clinical features of dizziness include; vertigo, vomiting, headache, nausea, ringing in the ears, hearing loss, sweating, fainting and falls. The prevalence of the clinical features increases with age.

Vertigo

• Vertigo usually involves visualisation of tilting, spinning, or dropping in the environment. Vertigo episodes are commonly caused due to inner-ear infections. In cases of hearing loss, ear pressure and tinnitus.
• The period of vertigo lasts for 20 minutes to 24 hours.
• Acute monophasic vertigo can generally occur suddenly and can last for weeks, months to years, while episodic vertigo occurs in episodes and can last for seconds to hours.
• Positional vertigo is caused when the person displays movements or certain positions.

Headache

• Headache is a common clinical feature of dizziness and is associated with migraine-related dizziness. Earlier history of viral infections, colds or frequent episodes of Meniere disease also result in headache.

Gait ataxia

• Various cerebral diseases result in gait ataxia, which is more prevalent in older people.

Vomiting and nausea

• Vomiting and nausea can be due to anxiety, drop in blood pressure, use of medications, migraines and inflammation in the inner ear.

Clinical Investigations of Dizziness

Currently, TiTrATE is the novel diagnostic method used for the determination of the causes of dizziness. The method involves information and understanding on the Time of the symptom occurrence, Trigger of the symptom, and Targeted examination of the symptoms.

Physical examination

• Physical examination provides the basic information on the vital signs and underlying conditions of the patient experiencing episodes of dizziness. The examination involves cardiac and neurologic examination, orthostatic BP measurement, nystagmus assessment, and Dix-Hallpike manoeuvre.
• The head –impulse, nystagmus and test of skew examination (HINTS) helps in differentiating central and peripheral aetiologies.
• Ear examination provides important information to the physician on presence of infection or inflammation in the inner ear.
• Neck examination involves understanding on the flexibility and motion effects on the patient.

Orthostatic blood pressure measurement

• Blood pressure measurement of the patient in supine position and when he stands provides information on presence of orthostatic hypotension.
• Presence of orthostatic hypotension is considered to be sufficient for development of the symptoms. However, more than 40mm Hg decrease in orthostatic Systolic blood pressure (SBP), 90 mm Hg or low SBP in standing position and decrease in orthostatic mean arterial pressure of 20 % are considered symptomatic for the condition.

Nystagmus

• Nystagmus evaluation is a vital component for diagnosis of peripheral vestibular disorders. This test is at times referred to as static positional testing and is different from Dix-Hallpike manoeuvre as it identifies the presence of anterior and posterior canal BBPV.
• Presence of BBPV is diagnosed through direction changing horizontal nystagmus or positional torsional nystagmus.
• Vestibular neuritis is diagnosed through unidirectional horizontal nystagmus.
• Lesions in the lower cerebellum does not result in unidirectional horizontal nystagmus.

Spontaneous nystagmus

• The most common oculomotor issues observed in dizziness involves presence of spontaneous nystagmus. This indicates imbalance in the peripheral or central vestibular system.
• Presence of spontaneous vertical nystagmus commonly indicates a central lesion. After observing eye movements in the first gaze the eye movements in each direction are also observed.
• Persistent nystagmus which occurs while looking at 30 degrees to the side is considered as pathological finding. Gaze-evoked nystagmus which are bi-directional in nature are generally caused due to central lesions

Positional testing

• Positional testing commonly triggers central and peripheral nystagmus. This is performed using the Dix-Hallpike manoeuvre

1. This method helps in diagnosis of Benign paroxysmal positional vertigo (BPPV). The examination is performed by seating the patient on a flat table.
2. The physician turns the patient’s head from one side to another at 45 degrees and immediately lays the patient in supine position with their head hanging at 20 degrees over the edge of the table.
3. The physician observes the patient’s eyes for 30 seconds and the exercise is repeated on the opposite side. The method also helps in diagnosis of vestibular debris of the ear.
4. Spontaneous nystagmus is generally caused due to lesions in the cranial nerve VII and labyrinth. Electronystagmography tests for vestibular functioning are used for detection of nystagmus.

Balance and Gait testing

• In this test, the patient is observed during walking, tandem walking, and in Romberg position (with open and closed eyes). Gait impairment generally suggest presence of a neurological condition.
• Patients with labyrinth and eight nerve lesions display off-balance and those with bilateral vestibulopathy or peripheral neuropathy are unable to stand in Romberg position with their eyes closed.
• Swaying on one side in Romberg test indicates presence of vestibular dysfunction. Ataxia usually indicates cerebellar dysfunction and is characterized by slow, irregular and wide-based gait of the patient.

Radiography and Laboratory testing

• Radiography or laboratory testing for dizziness does not show any additional benefits for the diagnostic work-up of the patients. Studies have shown very low number of patients who displayed abnormal laboratory tests for explanation of dizziness.

Various causes of dizziness and diagnostic methods

Treatment and Management of Dizziness

Once the patient history and physical examination is performed, the physician should further place the diagnosis into one of the dizziness categories and decide upon the treatment plan for the patient. Patients with Meniere disease can lead to concurrent episodes of vertigo.

Pharmacological management

• For patients with migraine associated vertigo are subjected to migraine preventing medications for minimising the consequences of headache and thereby minimising the occurrence of vertigo.
• Patients with BBPV are subjected to 25-50 mg Meclizine, which is commonly used for reducing the symptoms of vertigo. High-dose oral corticosteroids like methylprednisolone (100 mg daily) are administered to patient with vestibular neuritis.
• For patients with orthostatic hypotension, the earlier prescribed drug regimen is reviewed.
• Midodrine which is an Alpha-1 agonist metabolite is titrated up to 10 mg for preventing supine hypertension. Fludrocortisone is further administered to increase sodium and water retention.

Non-pharmacological management

• Various non-pharmacological management methods like restriction on salt consumption, use of diuretics and other methods are used.
• Epley manoeuvre and vestibular rehabilitation are other treatment methods which include head and neck exercises and benign paroxysmal positional vertigo treatment are used.
• Other management interventions include effective sleep, good diet and exercise.
• Continuous monitoring of blood pressure, symptoms and potassium levels is important for management of orthostatic hypotension and thereby minimising the episodes of dizziness associated with it.