Vertigo and Dizziness: Assessment and Management

Understanding Dizziness and Vertigo: Key Distinctions

Dizziness affects 20% of adults and is common presenting complaint. Vertigo, a subtype, represents illusion of movement. Understanding distinguishing features guides diagnosis and appropriate treatment. Most causes are benign and treatable.

Dizziness Facts:

• Affects 15-20% of adults, increases with age
• Second most common chief complaint in primary care
• Benign paroxysmal positional vertigo (BPPV) most common (50% of cases)
• Fall risk increased 3x with untreated dizziness
• Most conditions treatable with high success rates

Types of Dizziness: Distinguishing Features

Vertigo (Vestibular)

• Sensation: Room spinning or illusion of movement
• Associated: Nausea, vomiting, imbalance
• Onset: Acute or episodic
• Vision: Nystagmus (involuntary eye movements)
• Severity: Often disabling during episodes

Presyncope (Pre-Fainting)

• Sensation: Lightheadedness, about to faint
• Associated: Blurred vision, numbness, chest discomfort
• Mechanism: Reduced cerebral blood flow
• Causes: Cardiac, vasovagal, orthostatic hypotension

Disequilibrium (Balance Disorder)

• Sensation: Unsteady or off-balance feeling
• No vertigo: Room not spinning
• Causes: Neurological, musculoskeletal, medication
• Seen in: Aging, Parkinson's, cerebellar disease

Common Causes of Vertigo

Benign Paroxysmal Positional Vertigo (BPPV)

Overview

• Cause: Loose calcium crystals in inner ear (canaliths)
• Triggers: Certain head positions (head back, rolling in bed)
• Prevalence: 50% of vertigo cases
• Duration: Brief episodes (seconds to minutes)
• Prognosis: Excellent with treatment

Diagnosis

• Dix-Hallpike maneuver: Gold standard diagnostic test
• Positive test: Vertigo and nystagmus reproduced
• Imaging: Usually not needed

Treatment - Epley Maneuver

• Success rate: 80-90% resolution in one session
• Mechanism: Repositions crystals back to utricle
• Performed by: Healthcare provider or self-directed
• Repeat: May need 2-3 sessions if recurrence

Vestibular Neuritis

• Cause: Inflammation of vestibular nerve
• Onset: Sudden, severe vertigo
• Duration: Days to weeks of symptoms
• Recovery: Gradual over weeks with vestibular rehabilitation

Meniere's Disease

• Features: Vertigo, hearing loss, tinnitus, aural fullness
• Cause: Fluid buildup in inner ear
• Triggers: Stress, high salt intake, caffeine
• Treatment: Diuretics, salt restriction, vestibular rehabilitation

Assessment and Diagnostic Testing

Clinical History

• Detailed description of sensation (spinning vs lightheaded)
• Onset (sudden vs gradual) and duration
• Associated symptoms (hearing loss, tinnitus, headache)
• Triggering positions or movements
• Recent viral illness or head trauma

Physical Examination

• Vital signs: Check for orthostatic hypotension
• Nystagmus assessment: Direction and characteristics
• Dix-Hallpike test: Reproduce vertigo positionally
• Romberg test: Balance assessment
• Gait assessment: Ataxia or abnormal pattern

Diagnostic Tests

• Audiometry: Assess hearing (Meniere's disease)
• Electronystagmography (ENG): Record eye movements
• Videonystagmography (VNG): Video-based eye movement recording
• Caloric testing: Assess vestibular function
• MRI: If central cause suspected

Treatment Approaches

Medications for Vertigo

Vestibular Suppressants

• Antihistamines: Meclizine (Antivert)
• Anticholinergics: Scopolamine
• Use: Acute symptom relief
• Note: Don't address underlying cause

Nausea Management

• Ondansetron (Zofran) for severe nausea
• Prochlorperazine (Compazine)

Vestibular Rehabilitation

• Purpose: Retrains balance system
• Exercises: Gaze stabilization, habituation, balance training
• Timing: Begin early for better outcomes
• Effectiveness: 80-90% improvement with therapy

Epley Maneuver (BPPV Treatment)

• Head positioning sequence to reposition crystals
• 1. Head hanging off bed (60 sec)
• 2. Roll head to opposite side (60 sec)
• 3. Sit up slowly
• Success rate 80% in one session

Prevention and Fall Safety

Fall Prevention Measures

• Remove tripping hazards (throw rugs, clutter)
• Install handrails and grab bars
• Improve lighting throughout home
• Wear proper footwear with good support
• Use assistive devices (walker, cane) as needed

When Experiencing Vertigo

• Sit or lie down immediately
• Avoid sudden position changes
• Move slowly and deliberately
• Hold onto stable objects
• Avoid driving until symptom-free

Key Takeaways: Vertigo and Dizziness Management

• Distinguish between vertigo, presyncope, and disequilibrium
• Recognize BPPV (most common, easily treated)
• Perform diagnostic testing when indicated
• Treat vertigo with appropriate medications and positioning
• Engage in vestibular rehabilitation for balance recovery
• Implement fall prevention measures
• Seek specialist evaluation if not improving
• Address underlying causes (cardiac, neurological)