King Khalid University
College of medicine
Department of family & community medicine
Dizziness
Prepared by :
- Abdullah Alshehri
- Fahd Alshehri
-Mazen Alshahrani
-Ali Almater
-Abdurrahman Al qahtani
- Abdullah Alammar
- Khalid Aldossari
Supervised by : Prof. Khalid S. Al-Gelban
Clinical scenario .
 Mona Mohd. , a 43 old woman, she is housewife came to
PHCC with chief complaint …
Mona : dr. I sometimes felt dizzy in the last 2 months
DR. : When you have dizzy spells, did you feel light-headed or
do you see the world spin around you ?
Mona : I feel the world spin over around me .
DR : tell me about onset, frequency& severity ..
Mona : well doctor, it started gradually before 2 months , and I
feel dizzy 1 to 2 times a day , and it is not so severe .
 DR :for how long this dizzy reaming ?
Mona : 2-3 hours .
 DR : any aggravating or relieving factor ?
Mona : yes , aggravated by head movement and
Relieved by bed rest .
 DR : tell me about the associated complaints ?
Mona : sometimes .. Nausea and vomiting ?
 DR : is it associated with tinnitus or headache ?
Mona : yes , tinnitus in my Rt. Ear , and no headache .
 DR: is it associated with
any sort of deafness ?
Mona : only a little pit I feel
that in my Rt. Ear .
 DR; any ear discharge or
feeling fullness in the ear ?
Mona : No
 Any migraine headache ?
Mona : No
 Any recent upper respiratory infection or fever ?
 Mona : No .
 Any head or ear trauma ?
 Mona : no
 Any sleep disturbance , loss of appetite , loss of interest ?
 Mona : No .
 Any previous angina , MI ?
 Mona : No
 Are you HTN , D.M. , smoker ?
 Mona : No
 Any medicine you use ?
 Mona : Sometimes Paracetamol .
 Any similar condition in your family ?
 Yes , my father complain from the same problem before one year ,
and now he is O.K.
How to approach to
the patient with
dizziness ?
Objectives
 Definition .
 Epidemiology .
 Classification ( according to patient history ) .
 Causes .
 DDx.
 Hx.
 Physical examination .
 Investigations
 Management
 Referral .
Objectives
 Definition .
 Epidemiology .
 Classification ( according to patient history ) .
 Causes .
 DDx.
 Hx.
 Physical examination .
 Investigations
 Management
 Referral .
Dizziness is defined as perception or sensation of
oneself or one`s environment is moving or room
spinning .
It also refers to sensation of lightheadedness or
faintness to spinning or a feeling of imbalance .
Objectives
 Definition .
 Epidemiology .
 Classification ( according to patient history ) .
 Causes .
 DDx.
 Hx.
 Physical examination .
 Investigations
 Management
 Referral .
Dizziness is common in :
 Elderly .
 Middle aged .
 Females .
 Psychiatric patients .
 Patients on drugs .
 Patients suffering from chronic diseases such diabetes and
hypertension.
1- 5 % of the total visits to primary health care setting is due to dizziness.
15-25% of patients come to emergency departments with dizziness are admitted to hospitals .
5% of patients presented to primary health care with dizziness are referred to hospitals .
Majority of the patients presenting to primary health care settings with dizziness are self-limited.
Approximately , 33% of people suffer from dizziness by the age of 65 years and 50% of them will suffer from dizziness by
the age of 80 years .
Most of the patients presenting with vertigo to primary health care are due to peripheral causes .
Objectives
 Definition .
 Epidemiology .
 Classification ( according to patient history ) .
 Causes .
 DDx.
 Hx.
 Physical examination .
 Investigations
 Management
 Referral .
1- vertigo : The main causes of vertigo are benign paroxysmal positional
vertigo, Meniere disease, vestibular neuritis, and labyrinthitis .
2- disequilibrium : Parkinson disease and diabetic neuropathy
should be considered with the diagnosis of disequilibrium
3- presyncope : Many medications can cause presyncope, and
regimens should be assessed in patients with this type of dizziness .
4- lightheadedness : Psychiatric disorders, such as depression,
anxiety, and hyperventilation syndrome, can cause vague lightheadedness
Cause
category of
dizziness
Pathophysiology
Diagnostic criteria
Benign paroxysmal
positional vertigo
Vertigo
Loose otolith in
semicircular canals
causing a false sense of
motion .
Positive findings with
Dix-Hallpike
maneuver; episodic
vertigo without
hearing loss .
Hyperventilation
syndrome
Lightheadedness
Hyperventilation
causing respiratory
alkalosis; underlying
anxiety may provoke
the hyperventilation .
Symptoms
reproduced with
voluntary
hyperventilation .
Meniere disease
Vertigo
Increased
endolymphatic fluid in
the inner ear .
Episodic vertigo with
hearing loss .
Cont..
cause
category of
dizziness
pathophysiology
Diagnostic criteria
Migrainous vertigo
(vestibular migraine)
vertigo
Uncertain; one
hypothesis is that
trigeminal nuclei
stimulation causes
nystagmus in persons
with migraine .
Episodic vertigo with
signs of migraine, plus
photophobia, or aura
during at least two
episodes of vertigo .
Orthostatic
hypotension
Presyncope
Drop in blood
pressure on position
change causing
decreased blood flow
to the brain, adverse
effect of multiple
medications
Systolic blood pressure
decrease of 20 mm
Hg, diastolic blood
pressure decrease of
10 mm Hg, or a pulse
increase of 30 beats
per minute .
Parkinson disease
Disequilibrium
Dysfunction in gait
causing imbalance and
falls
Shuffling gait with
reduced arm swing
and possible hesitation
Cont..
cause
Category of
dizziness
pathophysiology
Diagnostic
criteria
Peripheral
neuropathy
Disequilibrium
Decreased tactile
Decreased sensation
response when
in lower extremities,
walking causes
particularly the feet .
patient to be unaware
when feet touch the
ground, leading to
imbalance and falls .
VERTIGO
 Otologic or vestibular causes of vertigo are the most
common causes of dizziness, and include benign paroxysmal
positional vertigo (BPPV), vestibular neuritis (viral infection
of the vestibular nerve), labyrinthitis (infection of the
labyrinthine organs), and Meniere disease (increased
endolymphatic fluid in the inner ear).
 An estimated 35 percent of adults 40 years and older have
vestibular dysfunction.
 Vertigo with hearing loss is usually caused by Meniere disease
or labyrinthitis, whereas vertigo without hearing loss is more
likely caused by BPPV or vestibular neuritis
 Episodic vertigo tends to be caused by BPPV or Meniere
disease, whereas persistent vertigo can be caused by
vestibular neuritis or labyrinthitis .
Vertigo
Central
Peripheral
Central
No hearing loss
No tinitus
Causes : - cerbrovascular causes
- MS .
- Drugs
(Vertebro-basillar insufficiency:
severe vertigo
hiccoughs
dysphagia
Dx: MRI )
Peripheral
Associated with hearing loss and
tinnitus.
Mostly due to 8th cranial nerve
etiology.
Causes :
- Benign Paroxysmal Positional
Vertigo BPPV
- Acoustic neuroma
- Labyrinthitis
- Menier’s disease
- Perilymph fistula
BPPV
ONLY symptom is: VERTIGO.
No hearing loss, No tinnitus.
Comes when patient is getting up.
Mostly due to otoliths ‘ear stones’.
Dx: Dix-Hallpike test
Rx: Positional maneuvers to dislodge the otoliths.
The Epley maneuver.
This maneuver is used to treat benign positional vertigo by returning displaced
otoliths to the utricle. If vertigo occurs during any of the positions, that position
is held until the vertigo subsides.
Acoustic Neuroma
Shwanoma of the 8th cranial nerve.
Not related to patient’s position.
Unilateral hearing loss
Unilateral Tinnitus.
ATAXIA.
Dx: CT, MRI
Rx: Surgery
Labyrinthitis
Not related to patient’s position.
Hearing loss.
Tinnitus.
SINGLE episode.
Recent VIRAL illness.
Rx: self limited.
Menier’s Disease
Over-production of endolymph.
Not related to patient’s position.
Hearing loss.
Tinnitus.
MULTIPLE RECURRENT episodes.
Rx: Low salt diet.
Diuretics.
Surgery.
Perilymph Fistula
Not related to patient’s position.
Hearing loss.
Tinnitus.
Hx. of TRAUMA.
Rx: Resolves spontaneously.
Surgical repair.
Migrainous vertigo or , vestibular migraine
 ,, is another underlying cause of vertigo that affects about 3
percent of the general population and about 10 percent of
persons with migraine
 Diagnosis of migrainous vertigo is established in patients with
a history of episodic vertigo with a current migraine or
history of migraine and one of the following symptoms
during at least two episodes of vertigo: migraine headache,
photophobia, phonophobia, or aura.
PRESYNCOPE
 Cardiovascular causes of dizziness include arrhythmias,
myocardial infarction, carotid artery stenosis, and orthostatic hypotension. Of patients with supraventricular
tachycardia, 75 percent experience dizziness and about 30
percent experience syncope.
 Symptoms brought on by postural changes suggest a
diagnosis of orthostatic hypotension.
Cardiac syncope
MI:
ECG & cardiac enzymes.
Aortic stenosis:
Echocariography.
Arrhythmia:
ECG .
DISEQUILIBRIUM
 There are many underlying conditions that may cause a sense
of imbalance. Stroke is an important and life-threatening
cause of dizziness that needs to be ruled out when the
dizziness is associated with other symptoms of stroke.
However, other neurologic findings are generally present.
 In a population-based study of more than 1,600 patients, 3.2
percent of those presenting to an emergency department
with dizziness were diagnosed with a stroke or transient
ischemic attack (TIA), but only 0.7 percent presenting with
isolated dizziness were diagnosed with stroke or TIA.
 Poor vision commonly accompanies a feeling of imbalance,
leading to falls. The physician should inquire about a history
of other problems that may cause imbalance, such as
Parkinson disease, peripheral neuropathy, and any
musculoskeletal disorders that may affect gait.
 Use of benzodiazepines and tricyclic antidepressants increase
the risk of ataxia and falls in older persons.
LIGHTHEADEDNESS
 Psychiatric causes of lightheadedness are common, particularly anxiety;
therefore, questions about anxiety and depression should be included in the
patient history.
 In one study, about 28 percent of patients with dizziness reported symptoms of
at least one anxiety disorder.
 In another study, one in four patients with dizziness met criteria for panic
disorder.
 Up to 60 percent of patients with chronic subjective dizziness have been
reported to have an anxiety disorder.
 Depression and alcohol intoxication have also been found to overlap with
dizziness.
 Hyperventilation syndrome is an important cause of
lightheadedness. Although the condition can be associated
with anxiety disorders, many patients without anxiety
experience hyperventilation.
 Hyperventilation is defined as breathing in excess of
metabolic requirements, causing a respiratory alkalosis and
lightheadedness. Patients may sigh repeatedly and may have
associated symptoms, such as chest pain, paraesthesias, bloating,
and epigastric pain.
Objectives
 Definition .
 Epidemiology .
 Classification ( according to patient history ) .
 Causes .
 DDx.
 Hx.
 Physical examination .
 Investigations
 Management
 Referral .
what are the DDx. do you think ?
Differential Diagnosis
Acute life threatening :
a. Cerebral hemorrhage (stroke).
b. Myocardial infarction .
c. Cardiac arrhythmia .
Infectious :
a. Acute neurolabyrinthitis.
b. Acute vestibular neuritis.
c. Neuro-syphilis.
Serious:
a. Brain tumors
b. Drug overdose
c. Severe depression.
d. Aortic stenosis.
e.Acoustic neuroma
Metabolic:
a. Hyperglycemia.
b. hypoglycemia.
c. hypothyroidism
Psychiatric:
a. depression.
b. Anxiety
c. Stress
d. Panic attacks
Ear causes:
a. Benign positional vertigo
b. otitis media
c. Acute labyrinthitis
d. meniere`s disease
e. Acoustic neuroma.
f. peri-lymphatic fistula .
Central nervous system :
a. stroke.
b. Multiple sclerosis.
c. Brain tumors.
d. migraine.
e. epilepsy.
Objectives
 Definition .
 Epidemiology .
 Classification ( according to patient history ) .
 Causes .
 DDx.
 Hx.
 Physical examination .
 Investigations
 Management
 Referral .
Identify
• patient’s name
• Age
• Job
• Marital status
Explore chief complaint
Clarify the complaint
 Is it true vertigo?
 Is it light headedness?
 Is it pre-syncope?
Ask the patient ,
describe your
feelings !?
 Is it disequilibrium?
Vertigo: The patient feels perception or sensation of himself or his
environment is moving or room is spinning (False sense of motion,
possibly spinning sensation) .
Light headedness: It is a vague floating sensation (feeling
disconnected with the environment )
Pre-syncope: Feeling of an impending fainting but no loss of
consciousness.
Disequilibrium: An ability to keep balance usually associated with
unsteady gait.
 Duration ?
(second, minutes, hours, days)
 Frequency ?
(acute, recurrent, chronic)
 Intensity ?
(mild, moderate, severe)
 Aggravating factors ?
(sitting, standing, rolling over, bending over)
 Relieving factors ?
(sitting, standing, rolling over)
Ask about the associated symptoms ..
Neurological symptoms:
o Headache (migraine) ?
o Numbness, tingling ?
o Blurring of vision ?
o Body weakness ?
o Par aesthesia ?
• Ear symptoms:
o Hearing loss (Deafness) ?
o Tinnitus ?
o Ear pain ?
o Ear discharge ?
Head & Neck:
o Neck pain ?
o Head trauma ?
 Cardiovascular & Pulmonary symptoms:
o Chest pain ?
o Palpitation ?
o Dyspnea ?
o Chronic cough ?
General symptoms:
o Fever ?
o Weight loss ?
o Nausea ?
o Vomiting ?
Assess for Risk factors
 Head trauma ?
 Age <60 years
 Coronary heart disease (CHD) ?
 Diabetes Mellitus ?
 Hypertension ?
 Drugs ?
 Sexuality ?
Past history
 Similar attacks ?
 Head trauma ?
 Chronic Otitis Media ?
 Spondylosis ?
 Recent respiratory infections ?
 Head and neck surgery ?
Family history
 Similar problem in the family ?
Drug history
 Using drugs ?
(What are they, dose, why?)
 Abusing drugs ?
(What are they, dose, why?)
Cardiac medications
 Alpha blockers (e.g., doxazosin










[Cardura], terazosin)
Alpha/beta blockers (e.g., carvedilol
[Coreg], labetalol)
Angiotensin-converting enzyme
inhibitors
Beta blockers
Clonidine (Catapres)
Dipyridamole (Persantine)
Diuretics (e.g., furosemide [Lasix])
Hydralazine
Methyldopa
Nitrates (e.g., nitroglycerin paste,
sublingual nitroglycerin)
Reserpine
Central nervous system
medications
 Antipsychotics (e.g., chlorpromazine,




clozapine [Clozaril], thioridazine)
Opioids
Parkinsonian drugs (e.g., bromocriptine
[Parlodel], levodopa/carbidopa
[Sinemet])
Skeletal muscle relaxants (e.g., baclofen
[Lioresal], cyclobenzaprine [Flexeril],
methocarbamol [Robaxin], tizanidine
[Zanaflex])
Tricyclic antidepressants (e.g.,
amitriptyline, doxepin, trazodone)
Urologic medications
 Phosphodiesterase type 5 inhibitors
(e.g., sildenafil [Viagra])
 Urinary anticholinergics (e.g.,
oxybutynin [Ditropan])
Psychosocial history
 Idea:
What is the patient’s idea about dizziness?
 Concern:
What is the patient afraid of?
 Expect:
What are the expectations of the patient from his doctor to do?
 Effect:
What are the effect of dizziness on sleep? Daily activity and work?
 Depressed mood:
(take detailed history for depression)
 Stressed patient:
(explore the reasons)
 Anxious:
(look for reasons)
Other hidden agenda
 Afraid of malignancy ?
 Wants sick leave ?
 Want further investigation such as MRI ?
Objectives
 Definition .
 Epidemiology .
 Classification ( according to patient history ) .
 Causes .
 DDx.
 Hx.
 Physical examination .
 Investigations
 Management
 Referral .
Physical Examination
 Aims:
* To determine the diagnosis.
* To reassure the patient.
* To assess the severity of the condition.
The main goal of the physical examination is
to reproduce the patient's dizziness in the
office
General Examination
* Blood Pressure: (supine, sitting, standing)
 look for postural hypotension.
( blood pressure should be measured while the patient is in a supine
position and again at least one minute after the patient stands. A systolic
blood pressure decrease of 20 mm Hg, diastolic blood pressure decrease
of 10 mm Hg, or pulse increase of 30 beats per minute is indicative of
orthostatic hypotension )
* Pulse:
 look for arrhythmia.
* Temperature:
 high grade fever may indicate intracranial infections.
• Signs of anemia and polycythemia
 pallor and congested face.
Cardiovascular System
* Bruit  atherosclerosis.
* Signs of aortic stenosis.
* Arrhythmia.
Ear, Nose and Throat:
* Ear wax.
* Hearing tests (Weber & rinne’s).
Eyes:
* Visual activity.
* Nystagmus.
Nervous System
* Gait.
* Coordination.
* Muscle tone & power.
* Reflexes.
* Romberg test.
* Finger-nose test.
* Cranial nerves (2nd,3rd,4th,6th,7th).
Head & Neck:
* Head & neck local tenderness.
* Cervical spine tenderness and range of movement.
Special tests:
* Forced hyperventilation test
(20-25 breath/minute for 2 minutes).
* Positional testing for benign positional vertigo
(Dix-Hallpike maneuver).
Dix-Hallpike maneuve
A person is brought from sitting to
a supine position, with the head
turned 45 degrees to one side and
extended about 20 degrees
backward. Once supine, the eyes
are typically observed for about 30
seconds. If no nystagmus ensues, the
person is brought back to sitting.
There is a delay of about 30 seconds
again, and then the other side is
tested.
A positive Dix-Hallpike tests
consists of a burst of nystagmus
(jumping of the eyes
Objectives
 Definition .
 Epidemiology .
 Classification ( according to patient history ) .
 Causes .
 DDx.
 Hx.
 Physical examination .
 Investigations
 Management
 Referral .
Investigations:
Asking for investigations will depend upon the probable
diagnosis.
* CBC (if you suspect anemia, polycythemia).
* Fasting & random plasma sugar (hyper/hypoglycemia).
* ECG (to rule out arrhythmia).
* Audiometry (to rule in or rule out Menier’s disease).
* Calori test (to confirm benign positional vertigo).
* Plain x-rays (to rule out cervical spondylosis).
* CT scan or MRI (stroke & brain tumers).
* EEG (epilepsy).
Audiometer
Objectives
 Definition .
 Epidemiology .
 Classification ( according to patient history ) .
 Causes .
 DDx.
 Hx.
 Physical examination .
 Investigations
 Management
 Referral .
Management of common conditions
that present with dizziness
# Acute vestibulopathy.
# Benign paroxysmal positional vertigo (BPPV).
# Menier’s disease.
# Acute vestibulopathy:
*usually preceded by viral upper respiratory tract infectoins.
* Acute onset of vertigo.
* Last hours to days.
* Improves gradually.
* No hearing loss or tinnitus.
Cont.
* Acute phase is associated with horizontal nystagmus.
* Lie on the affected ear will limit the sensation of vertigo.
* Has benign self limited course:
 No need for any treatment except reassurance.
 Diphenhydramine 50 mg every 4-6 hourly.
# Benign paroxysmal positional vertigo
(BPPV).
* Affects all ages (mainly the elderly).
* F > M.
* Reccurs frequently for several days.
* Attacks usually brief (lasts < 1 minute).
* Not associated with nausea, vomiting, hearing loss or
tinnitus.
* The hearing test is normal.
* Diagnosis is confirmed by Dix-Hallpike maneuver.
Cont.
* Recovery is common & will take place within a week.
* Treatment includes:
- Explanation.
- Reassurance.
- Positional vestibular exercise.
- Drugs are not recommended.
Menier’s disease
* Occurs due to accumulation of endolymph.
* Age: 30 – 50 years.
* Triad of diagnosis are:
 vertigo, vomiting, and tinnitus.
* Additional feature:
 progressive neurosensory deafness.
* Acute onset.
* Patients do not like head movement.
* Nystagmus occurs during attacks.
Cont.
* Audiometry: reveals sensori-neural deafness (low tone).
* Treatment includes:
- Reassurance & explanation.
- Reduce salt intake, coffee, tobacco.
- Betahistidine 8 mg orally TID.
- Hydrochlorothiazide 12.5 mg orally OD.
- Surgery may be needed in special cases.
Objectives
 Definition .
 Epidemiology .
 Classification ( according to patient history ) .
 Causes .
 DDx.
 Hx.
 Physical examination .
 Investigations
 Management
 Referral .
Referral of patients with dizziness:
Vertigo of uncertain diagnosis.
Suspicion of tumor.
Suspicion of stroke.
Suspicion of chronic otitis media.
Vertigo following head trauma.
Menier’s disease.
Benign positional vertigo that does not improve with home.
Suspected cardiac causes.