Dizziness/Lightheadedness & Vertigo

Dizziness/lightheadedness, a sensation of nearly losing consciousness, must be distinguished from vertigo, a sense of impulsion (spinning), either of the environment or of the patient. Dizziness/lightheadedness usually results from a decrease in cerebral blood flow, resulting in momentary attention deficit (lasting milliseconds); vertigo usually occurs due to inner ear pathology. However, both dizziness/lightheadedness and vertigo may occur secondary to primary CNS pathology.

Differential Diagnosis

Dizziness/lightheadedness

• Transiently decreased cerebral blood flow
  –Hyperventilation
  –Vasovagal response
  –Congestive heart failure
  –Aortic stenosis
  –Hypertrophic cardiomyopathy
  –Hemorrhage
  –Dehydration or hypotension
  –Carotid sinus pressure
  –Cerebral artery thrombosis or embolism
  –Cardiac arrhythmia
  –Autonomic dysfunction (e.g., Shy-Drager syndrome)
  –TIA
  –Hypoxemia
  –Anemia

• Primary CNS dysfunction not associated with decreased blood flow
  –Migraine
  –Seizure
  –Severe electrolyte disturbance
  –Elevated intracranial pressure
• Panic attack
• Hyperventilation and/or anxiety
• Ictal aura
• Basilar migraine
• Drug intoxication (e.g., alcohol, sedatives, centrally-acting α-blockers)
• Allergic reactions
• Postconcussion syndrome
• Carbon monoxide poisoning
  Vertigo
• Peripheral vertigo (inner ear pathology)
  –Benign positional vertigo (>20% of cases)
  –Ménière's disease
  –Labyrinthine trauma
  –Labyrinthitis (viral)
  –Nonspecific or recurrent vestibulopathy
  –Bilateral vestibular loss
  –Acoustic neuroma
  –Autoimmune inner ear disease
• Central vertigo (CNS pathology)
  –Multiple sclerosis
  –Brainstem tumors
  –Labyrinthine trauma
  –Epileptic vertigo
  –Vertebrobasilar insufficiency
  –Tabes dorsalis
  –Friedreich's ataxia

Workup and Diagnosis

• A complete history and physical exam should include signs of dehydration, questions about excessive pressure on the neck, headaches, palpitations, history of heart disease, hearing loss, cardiac auscultation, orthostatic blood pressures, and complete ENT (including Weber's and Rinne's tests) and neurologic exams (gait)
• Laboratory evaluation may include CBC, electrolytes, calcium, glucose, BUN/creatinine, BNP, ESR, carbon monoxide level, pulse oximetry and/or arterial blood gas, eosinophil count, and stool occult blood testing
• Further testing may include ECG, 24-hour ECG monitoring, echocardiography, electronystagmography, hearing evaluation, head CT, EEG, MRI (head and/or labyrinth) and/or MRA (head or vertebrobasilar circulation)
• Vertigo may be evaluated with several specific maneuvers
  –Dix-Hallpike maneuver: Patient is sitting; rapidly move to supine position with head over back of table; observe for nystagmus (type and duration); repeat with head facing to the left and right (nystagmus that does not fatigue or is vertical is unlikely to be BPV)
  –Barany maneuver (Nylan-Barany maneuver) is similar to the Dix-Hallpike maneuver, but less sensitive

Treatment

• Treat the underlying disorder of lightheadedness
  –Rehydrate patient as necessary
  –Compensate for heart failure with inotropic agents, diuretics, and ACE inhibitors
  –Surgical intervention for valvular incompetence
  –Treat prodromal stroke (TIA) with aspirin or warfarin
  –Carotid endarterectomy for significant carotid stenosis
  –Acute migraine treatment with NSAIDs or triptans (e.g., sumatriptan); prophylaxis with valproate or tricyclic antidepressants;
  –Phenytoin or carbamazepine for seizures and auras

• Vertigo
  –Meclizine and/or reassurance and time are usually sufficient for benign positional vertigo
  –Modified Epley and/or particle repositioning maneuvers for positional symptoms
  –Diuretics and/or surgery for Ménière's disease
  –Central causes require disease-specific therapy

Book Source Details

• Book Title: In a Page: Signs and Symptoms
• Author(s): Scott Kahan, Ellen G. Smith
• Year of Publication: 2004
• Copyright Details: In a Page: Signs and Symptoms, Copyright © 2004 Lippincott Williams & Wilkins.

Other Book Chapters Related to Vertigo

Read excerpts from these other book chapters related to Vertigo:

Copyright Details: In a Page: Signs and Symptoms, Copyright © 2008 Williams & Wilkins.

More About Causes of Vertigo

• Back to symptom: Vertigo: Introduction (review 152 causes)
• Next Book Extract About Vertigo: Syncope (In A Page: Pediatric Signs and Symptoms)
• All Book Extracts: All Online Book Extracts for Vertigo

More About This Book: Title: In a Page: Signs and Symptoms Authors: Scott Kahan, Ellen G. Smith Publisher: Lippincott Williams & Wilkins Copyright: 2004 ISBN: 1-4051-0368-X

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• Dizziness (Handbook of Signs & Symptoms (Third Edition))

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