DIZZINESS / VERTIGO

Dizziness encompasses vertigo (spinning), presyncope (near-faint), disequilibrium (imbalance), and non-specific lightheadedness — subtype determines workup

SYMPTOMS / ASSOCIATED SX

• Vertigo: sensation of spinning of self or environment; episodic vs. constant; positional vs. spontaneous

• BPPV: brief (<1 min), triggered by position change (rolling over, looking up); no hearing loss

• Vestibular neuritis: sudden-onset constant vertigo; nausea/vomiting; no hearing loss; recent viral illness

• Meniere's: recurrent vertigo (20 min–12h) + unilateral hearing loss + tinnitus + aural fullness

• Central vertigo: gait instability, diplopia, dysphagia, dysarthria, facial numbness (EMERGENCY)

• Nystagmus: peripheral = horizontal, unidirectional, fatigues; central = direction-changing, vertical, non-fatiguing

DENIES

• New diplopia, dysarthria, dysphagia, facial droop, limb ataxia (posterior circulation stroke)

• Headache with vertigo (posterior fossa mass, cerebellar hemorrhage)

• Sudden unilateral hearing loss (labyrinthine infarct — AICA stroke)

• Palpitations/chest pain (cardiac presyncope misidentified as vertigo)

SOCIAL HISTORY

• Vascular risk factors (DM, HTN, HLD, smoking, AFib — posterior circulation stroke)

• Recent viral illness; aminoglycoside/cisplatin use (ototoxicity); alcohol (cerebellar ataxia)

MAIN ETIOLOGY

• Peripheral (80%): BPPV (most common cause of vertigo overall), vestibular neuritis, labyrinthitis, Meniere's disease

• Central (20% — high morbidity): posterior circulation stroke (PICA/AICA), cerebellar hemorrhage, MS, posterior fossa mass

• Other: orthostatic hypotension, medication toxicity, anxiety, anemia, hypoglycemia

MOST COMMON DDX

• BPPV (brief positional, Dix-Hallpike positive → Epley maneuver diagnostic + therapeutic)

• Vestibular neuritis (constant, spontaneous, post-viral; abnormal HIT = peripheral)

• Posterior circulation stroke (HINTS exam critical — see Pearls)

• Meniere's disease (recurrent triad: hearing loss + tinnitus + aural fullness)

• Orthostatic hypotension (orthostatic VS)

• Acoustic neuroma (progressive unilateral hearing loss + tinnitus; MRI with gadolinium)

DATA

• Dix-Hallpike test (BPPV: upbeat-torsional nystagmus toward affected ear; latency 5–10s; fatigues)

• HINTS exam (Head Impulse + Nystagmus + Test of Skew) — bedside, superior to early CT for posterior stroke

• Orthostatic VS; BMP, CBC, glucose; ECG

• MRI brain with DWI (posterior circulation stroke — CT insensitive in first 24–48h)

• CT head (hemorrhage, mass — with headache or focal deficit)

• ENT/audiology if Meniere's, sudden hearing loss, or recurrent peripheral vertigo

HOME MEDS

• Antihypertensives — hold if orthostatic

• Aminoglycosides — hold if ototoxicity; check levels

• Meclizine — acceptable for acute peripheral; avoid prolonged use (inhibits central compensation)

PLAN

• BPPV (posterior canal — most common):

  • Epley canalith repositioning maneuver — 80–90% success; can repeat same session

  • Brandt-Daroff exercises for home vestibular rehabilitation

  • Meclizine 12.5–25 mg PO TID PRN for nausea (short-term only)

• Vestibular neuritis (Strupp et al., NEJM 2004):

  • Methylprednisolone 100 mg PO daily tapering over 3 weeks — start within 72h

  • Meclizine 12.5–25 mg PO q6–8h ×3–5 days (acute phase only)

  • Ondansetron 4–8 mg IV/PO q6h PRN for nausea

  • Early vestibular rehabilitation PT (promotes central compensation)

  • Antivirals NOT indicated (no added benefit per Strupp)

• Posterior stroke:

  • Stroke team activation; MRI DWI urgently

  • DAPT (aspirin 325 mg + clopidogrel 75 mg ×21 days per POINT/CHANCE) vs. anticoagulation if cardioembolic

  • Neurology consult urgently

• Meniere's disease:

  • Low-sodium diet (<1.5–2 g/day); HCTZ 25–50 mg PO daily

  • Acute attacks: meclizine + benzodiazepine PRN

  • Intratympanic gentamicin or dexamethasone (ENT-guided)

• Symptomatic: IV fluids if vomiting/dehydrated; antiemetics; bed rest short-term

• DISCHARGE:

  • BPPV: Epley and Brandt-Daroff home exercises; driving restriction until symptom-free

  • Vestibular neuritis: vestibular rehab PT; follow up 1–2 weeks

  • Posterior stroke: antiplatelet/anticoagulation; BP management; neurology; driving restrictions

RED FLAGS

• HINTS positive for central: normal HIT (no catch-up saccade) + direction-changing nystagmus + skew → STROKE; MRI urgently

• New headache + vertigo → CT head; posterior fossa hemorrhage/mass until excluded

• Dysphagia + dysarthria + facial numbness + limb ataxia → Wallenberg (PICA infarct) — stroke alert

• CT insensitive for posterior fossa stroke in first 24–48h — normal CT does NOT exclude ischemic stroke

• Acute cerebellar hemorrhage + ataxia → neurosurgery emergency

SENIOR IM RESIDENT PEARLS

• HINTS exam (Kattah et al., Stroke 2009): sensitivity 100%, specificity 96% for central vertigo — superior to early MRI DWI

• Head Impulse Test: catch-up saccade = peripheral (reassuring); NO catch-up saccade = central (alarming)

• BPPV is the most common vestibular disorder — up to 50% lifetime prevalence; Epley is 90% effective

• Meclizine >72h inhibits central vestibular compensation and prolongs recovery — taper quickly; transition to vestibular PT

• Common mistake: CT head "ruling out" posterior stroke — CT misses up to 50% of posterior fossa ischemic strokes; always get MRI DWI

• Strupp et al. (NEJM 2004): methylprednisolone improved vestibular function recovery; antivirals did not add benefit