Hi everyone, my name is Michael Kim, and I am currently a specialist trainee year 6 (ST6) at the North East London Deanery. One of the presentations in the ED that I used to dread facing is vertigo. We all know the story: a middle aged woman with persistent vertigo, unable to eat, drink or even walk herself to the toilet. She would invariably be admitted to a CDU bed, despite your valiant efforts to relieve her symptoms with endless amount of anti-emetics and intravenous fluids. And all this time, there are gnawing doubts running through your mind: what if she’s had a stroke? Have I done the Hallpike correctly?
It was only when I had a teaching session from Dr Diego Kaski, a neurology registrar, that I could feel the sense of clarity and confidence return to my practice in dealing with patients with vertigo. Unfortunately I was unable to record the entire talk, so he has kindly written a short blog on some of the tips on dealing with this tricky presentation.
The portion of the talk that I did manage to video is a beautiful demonstration of how Dix-Hallpike manoeuvre should be performed. This is an essential skill for any ED physician, as the overwhelming majority of patients presenting with vertigo will have benign paroxysmal positional vertigo (BPPV). The video goes on to demonstrate the two main treatment manoeuvres for BPPV: Epley and Semont, the latter being the simpler and the easier one to remember and perform.
Ever since I recorded the video I used the Semont manoeuvre to treat BPPV in several patients, with an alarming success rate. Some even managed to walk out symptom free within 4 hours, thereby saving both time and a CDU space. Here is the blog, and enjoy the video clip.
Practical approach to dizziness
RCEM blog
Dr Diego Kaski
Dizziness accounts for over many general practice visits in the UK and is associated with significant morbidity 1. Although in the acute setting the most frequent diagnostic errors concern differentiating central from peripheral causes of vertigo 2, even when a peripheral cause of vertigo is identified, it is often incorrectly labeled as ‘viral labyrinthitis’ to encompass most inner ear disorders of presumed benign origin. A good long-term clinical outcome in these patients depends on a correct initial diagnosis. Vertigo is simply the illusion of movement but patients often use the terms ‘vertigo’ and ‘dizziness’ to describe a variety of subjective sensations. If the patient finds it difficult to explain their sensation, offer words like ‘merry-go-round’, ‘rocking like on a boat’, ‘unsteadiness’, or ‘light-headedness’. This can help distinguish whether the problem is ‘in the head’ or ‘in the legs’!
Table 1 summarises the commonest causes of vertigo in acute and chronic settings. When making a diagnosis in such patients, it may be helpful to have in mind these common diagnoses and determine into which the patient best fits, rather than attempting to formulate a large differential based on the history and examination findings.
Table 1: Common causes of vertigo in general practice
| Diagnosis | Clinical features | Examination | Investigation | Treatment |
| PERIPHERAL | ||||
| Benign paroxysmal positional vertigo | Sudden onset brief attacks of spinning vertigo, and imbalance triggered by changes in head position (bending down, looking up, or turning over in bed) | Positive Hallpike manoeuvre with vertigo, and nystagmus (torsional and upbeat for posterior canal BPPV) | Nil |
Particle repositioning manoeuvre (Epley or Semont)
|
| Vestibular neuritis | Vertigo, nausea/vomiting, and imbalance developing over minutes to hours.Symptoms are worse on movement.Constant oscillopsia initially (hrs). | Unidirectional horizontal (+ torsional) spontaneous nystagmus. Abnormal head impulse test, when turning the head towards the side of the lesion. | NilDiagnosis can be confirmed withbithermal caloric | Bedrest and anti-emetics for max of 3 days. Encourage mobility early.Vestibular rehabilitation if symptoms persist. |
| Meniere’s disease | Sudden onset severe vertigo, nausea, vomiting, imbalance, hearing loss, tinnitus, and aural fullness. | Spontaneous nystagmus with horizontal/torsional component. Abnormal head impulse test, impaired hearing. | Audiogram +/- Caloric and vestibular evoked myogenic potentials | High-dose betahistine, intratympanic dexamethasone or gentamicin. |
| CENTRAL | ||||
| Vestibular migraine | Episodic vertigo and imbalance often associated with nausea, photophobia, phonophobia, and aversion to movement. Headache may or may not be present. | Normal, or there may be nystagmus (spontaneous, gaze-evoked, or positional). | May requireMRI scan if first presentation | Anti-migraine prophylaxis (propranolol, amitriptylline,topiramate, pizotifen etc.) |
| Posterior circulation stroke | Sudden onset vertigo, headache, vomiting and imbalance. | Gaze-evoked nystagmus, broken smooth pursuit, limb ataxia, gait ataxia, positional downbeat nystagmus | CT or MRI brain | Treatment of stroke |
| NON-VESTIBULAR | ||||
| Postural hypotension | Recurrent episodes of dizziness, lightheadedness, or imbalance. Worse in the morning. Triggered by standing from sitting, or sitting from lying. | Usually normal | Postural bloodPressure recordings | Adequate hydration, reducing or stopping offending medication, compression stockings, tilting head of bed.Fludrocortisone for resistant orthostatic hypotension. |
| Anaemia | Recurrent episodes of light-headedness, often associated with palpitations. May present with blackouts. | Pallor | Full blood count | Treatment of underlying cause; iron replacement; blood transfusion |
| Anxiety | Episodic or chronic dizziness, usually a sensation of self-motion, accompanied by autonomic symptoms, and catastrophic fears. Avoidance behaviour. | Normal | Thyroid function tests, ECG | Reassurance, explanation of symptoms. Cognitivebehavioural therapy. Anxiolytics or antidepressants |
Red flags in cases of acute dizziness include unilateral hearing loss, abnormal neurological symptoms or signs, new headache, and a normal VOR (head impulse test). If present, the clinician should think of possible more serious causes such as posterior circulation stroke. Hearing and otoscopy are normal in VN and most other harmless causes of dizziness.
It is usually possible to make a positive diagnosis in patients presenting with dizziness, particularly in the acute phase. Where no diagnosis, or an incorrect one, is made acutely, this increases the probability of patients developing chronic dizziness, which is much harder to treat.
References
- Yardley L, Owen N, Nazareth I, Luxon L. Prevalence and presentation of dizziness in a general practice community sample of working age people. The British journal of general practice : the journal of the Royal College of General Practitioners. 1998; 48(429): 1131-5.
- Royl G, Ploner CJ, Leithner C. Dizziness in the emergency room: diagnoses and misdiagnoses. Eur Neurol. 2011; 66(5): 256-63.
Biography
Dr Diego Kaski is a Neurology Registrar at the National Hospital for Neurology and Neurosurgery in London, and an honorary clinical research fellow at Imperial College London. He has a special interest in Neuro-otology having completed a PhD at Imperial College London investigating the cortical mechanisms underlying human spatial navigation under the supervision of Professor Bronstein. He has also undertaken extensive research into the cortical mechanisms of human gait and balance, and the application of non-invasive brain stimulation techniques in the treatment of neurological gait disorders.
Vertigo peer review feedback 1 (2) Vertigo peer review feedback 2
Why on earth isn’t this listed somewhere as self care? Thank you for curing my dizziness without me needing to see a doctor!
Obviously the Semont is effective.
The Epley is too. As long as one learns how to do one of them properly, the patients will benefit.
Whether you choose Semont or Epley is probably more related to physician preference than efficacy or patient comfort.
Hi – Very useful video – thanks for posting it.
One possibly erroneous fact I wanted to bring to your attention: “Dizziness accounts for over 20% of general practice visits in the UK”. This is not supported by the cited paper, Yardley et al (1999), which states instead that “more than one in five respondents experienced dizziness during the past month”, and “of symptomatic responders, 40% had consulted their GP” (at some point).
In addition the studies I found, after a very quick trawl, support the notion that other problems are more common reasons to visit a GP. For example Avery et al (1999), looked at around 5,000 out of hours encounters in Nottingham and found that fever was the top presenting problem (10%), or Cooke et al (2013), who examined nearly 200,000 encounters in Australia and found that hypertension was the top problem (9%).
So I agree that dizziness is common and important (1% in the Avery paper), but maybe not 20% of all GP visits!
I didn’t come across a paper looking at UK data in a larger sample … so if anyone knows, please share.
Thanks again for posting!
Thanks Sabih, well spotted! I’ve updated the statement. Thanks again. Andy, Editor
Great advice on handling dizziness and the many kinds of it.