FYIIIIFIDI II II II DIF IIDIFIIIIIIIIIIIIIIIIIIIIDD Vertigo, Dizziness, and Headaches VERTIGO AND DIZZINESS AASS.yearold woman is brought tothe emergency department complaining of dizziness, She describes walking to her bathroom and experiencing a sudden feeling of nausea. She managed to reach the bathroom, where she vorited once and fll tothe flor. She was unable to get up off the floor and called 911. The patient describes a feeling ofthe room “spinning” around her, even though she realizes she isnot moving Definition. Vertigo is defined as a false sensation of movement, i., the sensation of move- ment in the absence of actual movement. Etiology. Vertigo may be caused by Meniere disease, labyrinthitis, positional vertigo, trau- ‘matic vertigo, perilymphatic fistula, and cervical vertigo. Other causes include vascular disease ofthe brain stem, arteriovenous malformations, brain tumor, multiple sclerosis, drug overdose, and vertebrobasilar migraine. Clinical Presentation. With the dizzy patient, the first step in the evaluation is to deter- mine the nature of the patient's complaints. “Dizziness” is a nonspecific term that does not provide meaningful information about what is occurring to the patient. Simply by taking a complete history, itis possible to determine whether the patient is experiencing vertigo or presyncope. Patients who experience vertigo will describe a sensation of movement without actually mov- ing. Commonly, patients will describe their environment spinning around them. Sensations of tilting, swaying, or falling forward or backward are all consistent with vertigo. Acutely, these episodes are commonly associated with nausea and vomiting Patients who complain of presyncope will describe their symptoms as “lightheadedness” or “feeling like P'm going to black out” Associated symptoms include generalized weakness, palpitations, and shortness of breath. It is essential to differentiate vertigo from presyncope because vertigo is usually a manifestation of neurologic disease, whereas presyncope is a car- inal manifestation of cardiovascular disease. ‘Once you are convinced by the history that the patient is indeed experiencing an episode of vertigo, the next diagnostic question you have to answer is whether the vertigo is secondary to peripheral or central vestibular disease. This distinction is important because the manage- ‘ment will differ between peripheral and central vertigo. Several points on history and physical examination will distinguish central from peripheral vertigo. KAPLAN) MEDICAL 363USMLE Step 2: Neurology 364 KAPLAN) MEDICAL Table III-4-1. Vertigo Central Vertigo Peripheral Vertigo [Onset Gradual Usually sudden "Tinnitus, hearing loss ‘Absent Present | Neighborhood signs Present ‘Absent | (diplopia, cortical blindness, dysarthria, extremity weakness/numbness) ‘Nystagmus Pure, vertical, does not | Mixed, horizontal, suppress with fixation, and | suppresses with fixation, | sultidirectional and unidirectional Once you have determined that the patient has peripheral vertigo there is a wide differential diagnosis that should be considered. ‘Meniere disease is characterized by tinnitus, hearing loss, and episodic vertigo. Each episode lasts 1 to 8 hours. The symptoms wax and wane as the endolymphatic pressure rises and falls. ‘The two most common causes of Meniere disease are syphilis and head trauma. Labyrinthitis presents with sudden onset of severe vertigo that lasts for several days with hear- ing loss and tinnitus. The disease frequently follows an upper respiratory tract infection. Benign paroxysmal positional vertigo is a cause of peripheral vertigo that characteristically is exacerbated by head movement or change in head position. Typically, episodes will occur in clusters that persist for several days. There will be a latency of several seconds after head ‘movement before the onset of vertigo. The vertigo usually lasts 10 to 60 seconds. Perilymphatic fistula is a form of peripheral vertigo related temporally to head trauma (blunt trauma to the ear, ea slap to the ear) or extreme barotrauma during air flight, scuba div- ing, or vigorous Valsalva maneuver. Central vertigo is caused by any cerebellar or brain-stem tumor, bleed, or ischemia. Drug toxicity or overdoses are important causes of central vertigo. Also, in the young patient with unexplained central vertigo, consider multiple sclerosis. ‘Treatment. Symptomatic treatment for peripheral vertigo includes meclizine or, in severe cases, diazepam. ‘Meniere disease is treated with a low-salt diet and diuretics. In patients who fail medical therapy, you can consider surgical decompression. Benign paraxysmal positional vertigo is treated with positional maneuvers that attempt to move the otolith out of the circular canals (c.g., Dix Hallpike and Barany maneuvers), Vertigo secondary to labyrinthits is treated symptomatically with meclizine and diazepam when the symptoms are severe. DIIIIIIIIIIIVIIDIIDIIIIVIVIIVIIIIIIIIIIIIIINIIIID