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Dizziness management in primary neurology clinic –
Byung In Han, Do Neurology Clinic, E-mail: han-byungin@hanmail.net
A. Introduction
The causes of dizziness are a constellation of conditions. They are so numerous that accounting for them in practice is challenging and sometimes leads to missing adequate diagnosis. Based on the circumstances that most clinicians are working at primary ambulatory clinics, the diagnosis needs to be focused on those encountered in this setting. This note presents frequently encountering causes of dizziness in primary ambulatory clinics, which are based on author's clinical experiences. The term dizziness and vertigo are used in the same meaning although they are defined differently in the literature. That is because differentiating the two symptoms does not always produce fruitful outcome. Details and references are omitted. This note focuses on practical know-how for diagnosis and management.
The common causes of dizziness in primary clinics are vestibular migraine (VM), benign recurrent vertigo (BRV), benign paroxysmal positional vertigo (BPPV), orthostatic hypotension (OH), Parkinson disease (PD), vestibular neuritis (VN), postural orthostatic tachycardia syndrome (POTS), fatigue related dizziness (FRD), Meniere’s disease (MD), and psychogenic dizziness. Rare causes of dizziness are vestibular paroxysmia (VP), somatosensory dizziness, cervicogenic dizziness, visual vertigo, primary disequilibrium of ageing (presbyastasis), transient ataxia after bed rest, persistent postural perceptual dizziness (PPPD), and mixed causes.
B. Common causes of dizziness in primary clinics.
1. Vestibular migraine (VM) and benign recurrent vertigo (BRV)
VM is a common cause of dizziness in primary clinics despite many literature reports claiming otherwise. The author’s quick intuition in getting this diagnosis is the presence of headache in the previous lifetime. Although the diagnostic criteria for migraine necessitates more than five times of headaches, the need of quick alleviation of the patient’s suffering is the rationale behind getting the quick presumptive diagnosis, regardless of how many headaches they have experienced.
Moreover, a tricky situation ensues when the patient has no prior headaches, which leads to a diagnosis of benign recurrent vertigo (BRV) that has similar pathophysiology. Because of this reason, in this note, sometimes the term VM is instead used where the term BRV should be used. There are no diagnostic findings for VM. But diagnostic symptoms were reported such as sit-up dizziness (SUD) and head shaking dizziness (HSD), which can be exploited as diagnostic clues during acute dizziness period. Managements are migraine preventive medications (Han BI. Medicine 2022).
2. Benign paroxysmal positional vertigo (BPPV)
Although many literatures say it is common, BPPV is not more common than we expect. The diagnosis is intuitively made based on the presence of positional nystagmus accompanied with dizziness. A tip for easily detecting the lesion site of horizontal BPPV was reported by Oh HJ and Han BI (Oh HJ. Neurology 2007). And that for predicting outcome of posterior BPPV treatment was reported by Han BI and Oh HJ (Han BI. Neurology 2006). The tricky situation is when no positional nystagmus is induced by examination. At this moment, diagnosis should rely on the dizziness characteristics.
BPPV may be the only condition that the dizziness is more severe in supine position than standing position, while other conditions usually present more severe dizziness in standing position than supine position. Another interesting point is that when "sitting up from Dix-Hallpike maneuver position" induces severe dizziness more than the “Dix-Hallpike maneuver” itself, VM is more likely. Nevertheless, habituation CRT benefits to both VM and BPPV. It is also noteworthy that BPPV is not yet reported under the age of 10.
BPPV without nystagmus is called “hidden BPPV” which makes therapists hesitate to undergo CRT. Even for hidden BPPV, CRT toward dizziness-provoking-positions relieves dizziness and ultimately achieves resolution. Author would like to call this “CRT for hidden BPPV” as a “habituation CRT”. The way to perform habituation CRT includes Dix-Hallpike maneuver, head-roll positioning, Epley maneuver, barbecue maneuver, and diagonal head movement. During habituation CRT, nystagmus may sometimes abruptly appear, and the lesion site of BPPV is discovered. Significant trials of CRT may be necessary to achieve full resolution of dizziness or nystagmus. Therapeutic sessions may extend to several days or weeks. In many cases, residual dizziness may persist for significant number of days or months even though nystagmus disappears in the early times. Habituation CRT should be undertaken. Approximately five consecutive visits are needed in most cases. The longest durations author had experienced were approximately 60 consecutive days for one patient and approximately 30 days for another patient.
3. Orthostatic hypotension (OH)
OH is a common cause of dizziness in elderly. Diagnosis is intuitive, when the SBP decreases significantly while standing. Blood pressurizing agent can be initiated under the caution of an excessive high SBP, say above 180 mmHg in any positions. Previously taken antihypertensive should be continuously taken unless supine SBP is too low, say below 120 mmHg.
The initial responses of medication are increases in both supine and standing SBPs and DBPs, but large difference between supine and standing SBPs might continue, say 140/100 in supine and 80/60 in standing of which the SBP difference is 60 mmHg. If the blood pressures are so high, say 190/100 in supine and 110/60 in standing, “night time blood pressure dip” can be obliterated leading to nocturnal hypertension. In this case, medication should be decreased or stopped and even antihypertensive should be given in the evening, although the patients do not have hypertension history.
Author’s impressions on OH are as follow: (1) whether the symptom continues or not, OH persists despite intensive medications. (2) Approximately half of the patients achieve symptom relief. (3) Approximately half of the patients develop to Parkinson disease.
4. Parkinson disease (PD),
In dizziness patients, if the gait slows and hands fumble, L-dopa can be tried, even though the patients were not diagnosed as PD. L-dopa is the least side-effect producing medication among PD medications. Relief in dizziness can be achieved within several days. Elderly patients generally have decreased eye movements including saccade, pursuit, and vestibulo-ocular reflex (VOR), so that enhancing these eye movements can benefit to them.
5. Vestibular neuritis (VN)
VN is not common in primary neurology clinic based on author’s experience. There are two types of VN which are unilateral VN (UVN) and bilateral VN (BVN). BVN can be found mostly in the elderly patients. VN is a clinical diagnosis, and there have been no diagnostic criteria for VN. Author’s diagnostic clues for VN in primary clinical settings are: (1) Dizziness is more severe in standing than supine position (2) Typical nystagmus (3) Positive stepping sign. Tests include caloric test and vestibular evoked myogenic potential (VEMP). Caloric test is sometimes hard to interpret which shows many false positives. VEMP is also sometimes not reliable. Therefore, diagnosis should rely more on history and physical examination.
VN is known to present with a monophasic occurrence, which occurs once and remits up to a compensated state. When dizziness occurs after prolonged remission periods, it is called “decompensation”, not recurrence. It is interesting that when decompensation occurs, stepping test shows rotating to the contralateral side of UVN. This may indicate that compensation is achieved so that the vestibular balance overturns.
6. Postural orthostatic tachycardia syndrome (POTS)
POTS is common in young subjects, usually below the age of 25. In primary clinical settings, subclinical POTS is more common than POTS, say less than 30 bpm increase from supine to standing position. The cause of subclinical POTS according to author’s experience is mostly insufficient diet and secondly is anemia. Unless anemia is accompanied, encouraging foods intake suffice for dizziness relief, and sometimes beta blocker also helps (Han BI. J Korean Neurol Assoc 2002)
7. Fatigue related dizziness (FRD)
If fatigue is assumed to be the only cause, FRD can be diagnosed, which is a diagnosis of exclusion. In many patients with dizziness of whatever the causes are, fatigue usually accompanies, so that relieving fatigue benefits to most dizziness patients. Details are described in author’s paper (Han BI. Frontier in medical case reports 2020).
8. Meniere’s disease (MD)
MD is not common in neurology clinic. MD is frequently misdiagnosed to VM. There are situations where it is not sure whether the patient has MD or VM, or even both. In this case, medications for both causes can be tried.
9. Psychogenic dizziness
Dizziness is both a result and a cause of many psychogenic conditions, especially anxiety. Dizziness and anxiety are reciprocal conditions. Dizziness in psychogenic dizziness is characterized by short lasting non whirling dizziness which usually occurs in less than one second, that ensues while undergoing attention demanding tasks. This brief dizziness of psychogenic dizziness can be confused with that of vestibular paroxysm (also known as “quick spin”) of which dizziness sometimes accompanies by neck movements. Psychogenic dizziness commonly results from prior experience of severe dizziness no matter what the cause is. Psychogenic dizziness should be treated by medication and VRT.
C. Rare causes of dizziness
Rare causes of dizziness in primary clinics are vestibular paroxysmia (VP), somatosensory dizziness, cervicogenic dizziness, visual vertigo, primary disequilibrium of ageing (presbyastasis), transient ataxia after bed rest, persistent postural perceptual dizziness (PPPD), and mixed causes.
1. Vestibular paroxysmia (VP)
Dizziness of VP is characterized by a quick spin-like dizziness, which makes it hard to differentiate from psychogenic dizziness. It is also hard to identify with MRI and MRA. Because patients with VP frequently accompanied with anxiety and neck pain, the management should be applied accordingly.
2. Somatosensory dizziness and cervicogenic dizziness
“Somatosensory dizziness” is not mentioned as a diagnosis in the literatures. Author suggests somatosensory dizziness definition as a dizziness that occurs from situation in which somatosensory input was disrupted. Cervical, lumbar, or leg’s conditions such as pain, trauma, neuropathy or surgical intervention are the exemplary. Cervicogenic dizziness or cervical vertigo is a subset of somatosensory dizziness and defined as a dizziness which occurs while moving the neck in standing position. Neck muscle relaxation performed by a physical therapy or medications should be given as management. If the causes are untreatable, VRT utilizing visual cue or using cane should be encouraged.
3. Visual vertigo
“Visual vertigo” is defined as being a syndrome where symptoms are triggered or exacerbated in situations involving rich visual conflict or intense visual stimulation (Bronstein AM. J Neurol Neurosurg Psychiatry 1995). Visual vertigo is caused by visual problems as well as vestibular disorder that develop a visual dependence. Management includes facilitating the use of somatosensory cues for balancing. Another example is a new eyeglasses wearer who feels dizziness, which is considered as a visual vertigo. Advice for them is to wait approximately 2 weeks until visual adaptation achieves.
4. Primary disequilibrium of ageing (or presbyastasis)
“Primary disequilibrium of ageing,” also known as presbyastasis, is a term used to describe the condition of elderly patients who present with imbalance and disequilibrium that cannot be ascribed to a particular state or single causative factor. (Furman JM. In: Furman JM, Cass SP. Vestibular disorders: Oxford university express. 2003). In advanced situation of presbyastasis, standing and walking should be discouraged, and instead, using a cane or a walker should be encouraged (Furman JM. Vestibular disorders. Oxford univ expr 2003).
5. Transient ataxia after bed rest
“Transient ataxia after bed rest” is defined as balance impairment after prolonged bed rest, which improves within 1 to 3 days (Haines RF. 1974). This dizziness occurs after certain period of bed rests, even though 2 weeks is enough to incur. Ensuing physical activity can relieve this condition (Haines RF. J Appl Physiol 1974).
6. Persistent postural perceptual dizziness (PPPD)
PPPD (pronounced as: "three-P-D" or "triple-P-D") is a chronic functional vestibular disorder that manifests with 3 or more months of dizziness, non-spinning vertigo, and unsteadiness (Staab JP. J Vestib Res 2017). Previously it was called chronic subjective dizziness (CSD), which defined as a condition with persistent, non-vertiginous dizziness, subjective imbalance, and hypersensitivity to motion cues in the absence of active vestibular deficits (Staab JP. Arch Otolaryngol Head Neck Surg 2005). The term CSD is recently substituted by PPPD. This condition develops when previous dizziness is not treated in correct time, and anxiety follows subsequently. PPPD should be managed by multidisciplinary ways including medications, physical therapy, and VRT.
7. Mixed causes
There are patients who suffer from combinations of many causes such as BPPV and VM, OH and PD, and VM and POTS. These conditions easily develop to PPPD so that timely and multidisciplinary managements should be applied.
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D. Summary
The followings are summarized tips to nurture reader's knowledge. Abbreviations are as follow: vestibular migraine (VM), benign recurrent vertigo (BRV), benign paroxysmal positional vertigo (BPPV), orthostatic hypotension (OH), Parkinson disease (PD), vestibular neuritis (VN), unilateral vestibular neuritis (UVN), bilateral vestibular neuritis (BVN), postural orthostatic tachycardia syndrome (POTS), fatigue related dizziness (FRD), Meniere’s disease (MD), vestibular rehabilitation therapy (VRT), simplified vestibular rehabilitation therapy (sVRT).
1. Prevalence of common causes of dizziness in different ages
* 2-15 years old : VM, BPV, POTS
* 16-25 years old : VM, POTS, BPV
* 26-65 years old : VM, BPPV, UVN, FRD
* Over 66 years old : OH, PD, VM, BVN
2. Step by step approach to diagnosis
(1) Examinations of positionings (such as Dix-Hallpike maneuvers and head roll test) and stepping test, which reveal BPPV, VN, and possibly VM.
(2) Visual observation for bradykinesia and gait pattern. This reveals PD.
(3) Physical examination for cervical muscle tenderness, which reveals cervicogenic vertigo.
(4) Caloric test and head up tilt test for VM, POTS, and OH.
(5) Detailed history for VM, psychogenic dizziness, FRD, and MD.
(6) Questionnaires such as DHI and FHI for psychogenic dizziness and FRD.
(7) Thorough history taking and physical examination for rare causes of dizziness such as somatosensory dizziness or visual dizziness.
3. Step by step approach to management
(1) Physical examinations:
(a) Nystagmus positive? à BPPV, VN à CRT, VRT.
(b) Sit-up dizziness or head shaking dizziness? à VM à medication.
(c) Bradykinesia? à PD medication.
(d) Neck pain? à cervicogenic vertigo à physical therapy.
(2) Tests:
(a) Head-up tilt test? à OH, POTS à medication.
(b) Caloric test? à VN à VRT.
(3) Find rare causes of dizziness.
(4) If the patient is unable to walk à fall prevention managements.
4. Easy ways to differentiate between BPPV, VN and VM.
(1) BPPV vs VN : If nystagmus direction changes by changing position between supine (face up) and nodding (face down), it is BPPV. Otherwise, VN or other conditions are more likely.
(2) BPPV vs VM : If dizziness is more severe while sitting up from Dix-Hallpike maneuver position than the Dix-Hallpike maneuvering itself, VM is more likely than BPPV.
5. When should brain imaging be taken?
Although there are many signs of dangerous causes leading to the necessity of brain imaging, author’s decision for imaging relies on consideration of old age, cerebrovascular disease risks, or unexplainable causes.
6. VRT vs sVRT.
VRT demands adequate manpower, space, and equipment (Han BI, J Clin Neurol. 2011). The alternative is sVRT which uses “Do smart®” PC program and “Do smart dizziness” application. The Do Smart® is a computerized exercise software developed by the author. sVRT enables clinicians to implement VRT to the patients with only one staff, in a small space, and no equipment (Han BI. Springer 2021).
E. Conclusion
This note covers most causes of dizziness which are encountered in primary neurology clinic. Those conditions resulting from central nervous system, side effects of medications, cardiovascular diseases, syncope and the likes are not described here. Author hopes the aforementioned knowledge may help primary neurology clinicians to equip better knowledge of dizziness
F. References
-Bronstein AM (1995) Visual vertigo syndrome: clinical and posturography findings. J Neurol Neurosurg Psychiatry 59:472-476.
-Furman JM, Cass SP. Disequilibrium of ageing. In:Furman JM, Cass SP. Vestibular disorders: A case-study approach. 2nd ed. Oxford university express 2003;128-132.
-Han BI. simplified vestibular rehabilitation therapy (sVRT). Springer 2021.
-Han BI, Kim JS, Song HS. Vestibular rehabilitation therapy: review. J Clin Neurol. 2011 December;7(4):184-196.
-Oh HJ, Kim JS, Han BI (corresponding author), Lim JG. Predicting a successful treatment in posterior canal benign paroxysmal positional vertigo. Neurology. 2007 Apr 10;68(15):1219-22.
-Haines RF. Effect of bed rest and exercise on body balance. J Appl Physiol. 1974;36(3):323-327.
-Han BI, Oh HJ, Kim JS. Nystagmus while Recumbent in Horizontal Canal Benign Paroxysmal Positional Vertigo. Neurology 2006;66:706-710
-Han B, Hong J, Oh S, Lee J, Bang O, Joo I, Huh K. Postural Orthostatic Tachycardia Syndrome. J Korean Neurol Assoc 2002;21(5):214-217.
-Han BI, Kim JS, Song HS. Vestibular rehabilitation therapy: review. J Clin Neurol. 2011 December;7(4):184-196.
-Han BI, Ko PW, Kim HA, Park SP, Lee HW. Fatigue related dizziness. FRONTIERS IN MEDICAL CASE REPORTS 2020;1;1-11.
-Han BI, Lee HW, Ryu SH, Park MS, Kim BK. Sit-up dizziness and head-shaking dizziness may be diagnostic symptoms of vestibular migraine. Medicine 2022; in press.
-Staab JP, Eckhardt-Henn A, Horii A, Jacob R, Strupp M, Brandt T, Bronstein A. Diagnostic criteria for persistent postural-perceptual dizziness (PPPD): Consensus document of the committee for the Classification of Vestibular Disorders of the Bárány Society. J Vestib Res. 2017;27(4):191-208. doi: 10.3233/VES-170622. PMID: 29036855.
-Staab JP, Ruckenstein MJ. Chronic dizziness and anxiety: course of illness affects treatment outcome. Arch Otolaryngol Head Neck Surg 2005;131675- 679.