Demystifying Dizziness: A Comprehensive Guide with Dr. David Hale

Approach to Dizziness

• 🎯 Dizziness is a vague term; focus on timing and triggers rather than patient descriptions.
• ⏱️ Categorize dizziness into acute vertigo, episodic vestibular syndrome (provoked or unprovoked), or chronic dizziness.
• ⚠️ Always assess for dangerous neurological causes (diplopia, dysarthria, dysphagia) and consider migraine, ear, heart, and vascular symptoms.

Episodic Provoked Vertigo: BPPV

• 💡 The most common cause of episodic provoked vertigo is Benign Paroxysmal Positional Vertigo (BPPV).
• ⚖️ Other considerations include orthostatic hypotension.
• 👂 If symptoms are spontaneous and longer-lasting, consider TIA, vestibular migraine, or Meniere's disease, assessing associated symptoms like hearing loss or headaches.

Diagnosing BPPV: Maneuvers and Pearls

• 🔬 Always perform the Dix-Hallpike maneuver (for posterior canals) and supine roll test (for horizontal canals) to diagnose BPPV, even if history is unclear.
• 👁️ Nystagmus must be present along with symptom reproduction to confirm BPPV.
• 🛠️ Use Frenzel goggles to remove visual fixation and improve nystagmus detection.
• 💡 Practical tip: Use pillows to position the patient's head correctly if exam tables are against a wall.

Explaining BPPV and Treatment

• 🖼️ Use visual aids like inner ear diagrams or phone pictures to explain BPPV to patients, describing crystals in fluid like snow in a snow globe.
• 🔄 The Epley maneuver is the primary treatment for BPPV.
• 💊 Short courses of anti-nausea medication can help patients tolerate maneuvers; avoid chronic vestibular suppressants.
• ☀️ Consider checking Vitamin D levels in patients with recurrent BPPV.

Acute Vestibular Syndrome (AVS)

• 🚨 AVS involves sudden, continuous vertigo, nausea, and vomiting, requiring differentiation between vestibular neuritis (peripheral) and stroke (central).
• 🏥 Patients with vascular risk factors and continuous vertigo should be sent to the Emergency Department.
• ➕ The HINTS+ exam (Head Impulse, Nystagmus, Test of Skew, Hearing assessment) is crucial for differentiating central vs. peripheral causes.
• 👂 Sudden hearing loss during AVS is a red flag for potential anterior inferior cerebellar artery (AICA) stroke.

HINTS Exam and Prognosis

• ⚡ A catch-up saccade on the head impulse test suggests a peripheral lesion.
• ↔️ Horizontal, unidirectional nystagmus is peripheral; any other pattern (vertical, torsional, direction-changing) is concerning for central causes.
• ⬆️ A skew deviation on the test of skew indicates a central lesion.
• 🧠 Vestibular neuritis is typically a one-time event; recovery involves vestibular physical therapy to retrain the balance system.

Chronic Dizziness: PPPD

• 🌐 Persistent Postural-Perceptual Dizziness (PPPD) is a functional neurologic disorder characterized by chronic, non-spinning dizziness, often triggered by anxiety or visual-perceptual stimuli.
• 🚶 Symptoms are typically worse with upright posture, movement, and busy environments.
• 🧠 Diagnosis involves ruling out other causes and meeting specific criteria for persistence, postural/perceptual symptoms, and a trigger.
• 🚢 Mal de debarquement syndrome (MDDS) is similar but specifically linked to exposure to passive motion.
• 💊 Treatment for PPPD includes diagnosis delivery, vestibular physical therapy, SSRIs/SNRIs at low doses, and cognitive behavioral therapy (CBT).