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Dizziness in the Outpatient Care Setting

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Dizziness in the Outpatient Care Setting Review Article Address correspondence to Dr Terry D. Fife, Barrow Dizziness in the Neurological Institute, 240 West Thomas Rd, Suite 301, Phoenix, AZ 85013, Outpatient Care Setting [email protected]. Relationship Disclosure: Terry D. Fife, MD, FAAN Dr Fife serves on the editorial boards of Barrow Quarterly and Neurology. Unlabeled Use of ABSTRACT Products/Investigational Purpose of Review: This article summarizes an approach to evaluating dizziness for Use Disclosure: Dr Fife discusses the the general neurologist and reviews common and important causes of dizziness unlabeled/investigational and vertigo. use of acetazolamide, Recent Findings: Improved methods of diagnosing patients with vertigo and venlafaxine, and zonisamide for the treatment of dizziness have been evolving, including additional diagnostic criteria and charac- vestibular migraine. terization of some common conditions that cause dizziness (eg, vestibular migraine, * 2017 American Academy benign paroxysmal positional vertigo, chronic subjective dizziness). Other uncommon of Neurology. causes of dizziness (eg, superior canal dehiscence syndrome, episodic ataxia type 2) have also been better clarified. Distinguishing between central and peripheral causes of vertigo can be accomplished reliably through history and examination, but imaging techniques have further added to accuracy. What has not changed is the necessity of obtaining a basic history of the patient’s symptoms to narrow the list of possible causes. Summary: Dizziness and vertigo are extremely common symptoms that also affect function at home and at work. Improvements in the diagnosis and management of the syndromes that cause dizziness and vertigo will enhance patient care and cost efficiencies in a health care system with limited resources. Clinicians who evaluate patients with dizziness will serve their patient population well by continuing to manage patients with well-focused workup and attentive care. Continuum (Minneap Minn) 2017;23(2):359–395. INTRODUCTION ment, or a feeling of spatial misper- Dizziness accounts for 5% of outpa- ception. That is, the patient senses that tient clinic presentations, making it a balance is impaired because of poorer- very common symptom in clinical than-normal stability on his or her feet medicine.1 Meanwhile, dizziness may or a feeling that he or she might fall. be one of the most challenging symp- This sensation may result from dizzi- toms to which physicians can ascribe a ness but may be caused by many other mechanism and cause.2 conditions, ranging from orthopedic to Dizziness is a term used commonly neurodegenerative disorders, which by patients and physicians alike that will not be discussed in this article. broadly refers to a misperception of spa- tial orientation. Because dizziness is so APPROACH TO PATIENTS nonspecific a term, it may refer to ver- WITH DIZZINESS tigo (the illusion of movement, especially The effective history and directed ex- rotation), disequilibrium or imbalance, amination can determine the source lightheadedness, or near faintness. of dizziness in many cases. The history Unsteadiness or disequilibrium indi- should identify what is meant by cate a feeling of reduced balance when ‘‘dizziness,’’ whether it is constant or standing or walking, but without vertigo, intermittent, provoked or random, and lightheadedness, an illusion of move- how long it lasts if intermittent. The Continuum (Minneap Minn) 2017;23(2):359–395 ContinuumJournal.com 359 Copyright © American Academy of Neurology. Unauthorized reproduction of this article is prohibited. Dizziness KEY POINT h Determining the history should also identify whether less helpful in narrowing the broad quality of dizziness is dizziness varies in certain circum- differential diagnosis. important but may not stances and if other symptoms accom- The quality-of-symptom approach be sufficient to make an pany the dizziness that might be clues to characterizing dizziness leads to 3,4 accurate diagnosis. to its nature and mechanism. many errors in diagnosis. In one Additional factors study by Hanley and O’Dowd,5 when including triggers, Clarifying ‘‘Dizziness’’ patients at an ambulatory clinic were duration, accompanying Dizziness may be caused by both given options to describe their dizzi- symptoms, and the benign and dangerous conditions, ness, 7.1% were unable to classify findings on examination so a careful history is important to im- their symptoms at all, and many are also needed to prove the diagnostic accuracy. When others chose multiple words simulta- narrow the range of the patient and clinician can come to neously to describe their sensation. possible causes. a clear and mutual understanding of While getting the patient to elaborate the patient’s description of dizziness, on the quality of the sensation is determining a clear cause is more helpful, more is needed to make a straightforward. However, substantial diagnosis (Case 2-1). limitations exist regarding how much the patient’s report of the quality of Narrowing the the sensation can be used to accurately Differential Diagnosis determine the mechanism, particularly What other symptoms or signs can in the acute care setting.3 Whether aidinnarrowingthepossiblemech- the patient states that he or she is spin- anisms and causes of the patient who ning or that the room is spinning is of experiences dizziness? As outlined in little importance. If the patient can Table 2-16, the patient’s descriptions identify clear rotational sensations, the of the timing, triggering events, and condition qualifies as vertigo, which associated symptoms are generally implies a greater likelihood of a vestib- more reliable than their descriptions ular mechanism. Other descriptions are of the quality of the dizziness.3 Case 2-1 A 46-year-old woman presented with a 4-month history of dizziness that she described as a constant feeling of instability; she sometimes felt as if she were spinning and at times felt that she could faint. Her symptoms had begun suddenly when at an out-of-town meeting while sitting at a table. She had begun to feel unstable and later became nauseated; she recalled a ‘‘topsy-turvy’’ spinninglike sensation that lasted the whole evening. She was alone and stayed in the hotel room, and eventually the spinning gave way to a constant swaying and floating feeling, which she continued to experience daily. She had not experienced any hearing loss, slurred speech, double vision, weakness, or numbness, and the nausea had not occurred since the initial onset of symptoms. Brain MRI was found to be normal on two occasions, and magnetic resonance angiography (MRA) of the head and neck, cardiac workup, and multiple blood tests were normal. At work, she had used all her vacation time and leave allowed by the Family and Medical Leave Act and was worried that she could no longer do her job as an information technology project manager. She was also reluctant to travel or drive. No abnormalities were found on examination. Continued on page 361 360 ContinuumJournal.com April 2017 Copyright © American Academy of Neurology. Unauthorized reproduction of this article is prohibited. Continued from page 360 KEY POINTS h The head impulse Comment. This case exemplifies a situation in which a patient probably test is a useful test of experienced a transient peripheral vestibular disturbance that caused vestibular function that spinning vertigo, but later a different form of dizziness became the can aid in the diagnosis predominant cause. This case shows that multiple descriptions of dizziness of vestibular disorders may be given by the patient; in this case, it was clarified that initially and requires no the patient experienced true vertigo but later experienced more of a special equipment. floating and swaying sensation. This could be due to poor compensation of unilateral vestibular loss but, more likely, the patient had a mild case h The head impulse test is of vestibular neuritis that created alarm and fear, and subsequently, done by grasping the chronic subjective dizziness related to anxiety ensued. patient’s head firmly on both sides, explaining the test to the patient, Useful Vestibular both sides, explaining the test to the and then making a Examination Techniques patient, and then making a very rapid very rapid but very Several examination techniques are but very small-amplitude turn of the small-amplitude turn helpful in evaluating the patient with head while the patient is instructed to of the head while the patient is instructed to vertigo and dizziness. These include look at the physician’s eye or some other look at the physician’s recognition of direction-fixed hori- fixed target. If the patient’s eyes never eye or some other zontal nystagmus and distinction from deviate from the target during or after fixed target. horizontal gazeYevoked nystagmus the head impulse, then vestibular func- h If the patient’s eyes (Table 2-1), head impulse testing, and tion related to the horizontal canal is never deviate from the the Dix-Hallpike maneuver (described normal or nearly normal in the ear on target during or after inthelatersectiononbenignparoxys- the side toward which the head is turned. the head impulse, then mal positional vertigo [BPPV]). If, however, the eyes moved with the vestibular function The head impulse (or head thrust) head and then must take a quick ex- related to the horizontal test is a simple test for detecting im- cursion or catch-up saccade back to the canal is normal or nearly paired vestibular function related to the target,
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