Published March, 2021
Meara Melton, MD
Expert review, pending
Objectives
- Use timing and triggers to differentiate dizziness into four limited differential categories. .
- Perform a bedside Dix-Hallpike exam to diagnose the cause of acute episodic, positionally triggered dizziness.
- Perform the HINTS exam to identify concerning features in continuous, spontaneous dizziness.
- Construct a four-step history and physical exam process to differentiate between benign and central causes of dizziness.
Teaching Instructions
Plan to spend at least 30-60 minutes preparing for this talk. Acute dizziness is a topic that is overwhelming and the goal of this talk is to make sure the learners have a general framework, understand key exams for diagnosis, and can identify life-threatening and time-sensitive situations.
This talk begins by presenting a systematic way for learners to think through the patient presenting with acute dizziness using a modified TiTrATE (Timing, Triggers And a Targeted Exam).1 It is designed to focus on the exam and workup for episodic, positionally-triggered symptoms and continuous, spontaneous symptoms. When introducing the framework, we review the Dix-Halpike maneuver and the HINTS exam. The learners then work through three cases, which highlight positive exam findings during diagnosis and management. If desired, this lecture can be divided into two 20 minute talks by introducing the framework in the first talk and working through the 3 cases in the second.
We have not yet created a Learner board so you will need to use the Presenter board to get a gist of the flow for this talk. On the PowerPoint, every box with a black cursor is an animated button. You will want to click these to advance through the presentation. Select the “home” icon to return to the algorithm at any time and the large blue arrow to return to the cases.
This talk can be presented in two ways:
- Project the “Interactive Board for Presentation”.
or
- Reproduce a drawing of the presentation on a whiteboard.
With either method, print out copies of the Learner’s Handout so they may follow along during the presentation and take notes as you expand on the decision tree and apply it through the three practice cases. Begin with reviewing the objectives for the session.
Objective 1
Use timing and triggers to differentiate dizziness into four limited differential categories
One of the key objectives of this talk is to establish a consistent framework that is easy to navigate. There are multiple ways to approach dizziness and many providers have been taught to think of it as vertigo, presyncope, disequilibrium, or lightheadedness. The challenge with this approach is that we often get nonspecific descriptions of dizziness from patients and struggle to put them in a category. TiTrATE is a diagnostic approach to determine the probable etiology of dizziness or vertigo. It uses the Timing of the symptom, the Triggers that provoke the symptom, And a Targeted Examination. The framework in this talk takes a modified approach to classify dizziness as 1) episodic positionally triggered, 2) spontaneous episodic, 3) Continuous due to trauma or toxins, or 4) continuous spontaneous.
Navigate through the algorithm by first selecting “Timing” to show how we characterize symptoms broadly as “episodic” or “continuous”. Here you should emphasize that triggered episodic vestibular syndromes last seconds to minutes, spontaneous episodic vestibular syndromes last minutes to hours, acute vestibular syndromes with the spontaneous onset, and constant vertiginous symptoms last hours to days.
Before expanding the 4 general categories, you may want to ask learners what history or exam findings they want to elicit in a patient presenting with dizziness. Some things to make sure are covered include:
- Assess cardiovascular risk factors, which would increase suspicion for possible posterior circulation stroke affecting the vestibular system.
- Ask about associated hearing loss or tinnitus.
- Assess for additional neurologic symptoms that suggest a central cause.
- Take a complete social history including substance use.
- Review medications/changes
Then click “Trigger” to reveal the four general categories. Reveal the algorithm for “spontaneous episodic” and “trauma or toxins” by clicking on them and briefly talk about how to approach these categories. Things to emphasize:
Spontaneous episodic: Briefly discuss that hearing loss can be evaluated using the Weber/Rinne tests. Meniere disease is often associated with hearing loss. Vestibular migraine should be considered in those with a history of migraine. Consider vasovagal causes or panic attacks in those with associated psychological stress.
Continuous due to trauma or toxins: Almost every class of medications can lead to symptoms of dizziness so we do not list them all out individually. Patients will often have had dizziness that persists, is usually not debilitating, and is not associated with other neurologic changes. Some of the biggest culprits are anti-epileptics, sedatives, anti-hypertensives and analgesics.
Objective 2
Perform a bedside Dix-Hallpike exam and orthostatics to diagnose the cause of acute episodic, positionally triggered dizziness
Click “Positionally triggered” to reveal that the Dix-Halpike maneuver should be performed to determine the diagnosis. Click on the image to link to a picture of the Dix-Halpike maneuver – click on the image to link to a video demonstrating the technique, if desired. If delivering this in person, you can have learners practice on one another at this point. Click the large blue arrow in the top-left corner to return to the framework. Share that a positive Dix-Halpike maneuver suggests the patient has BPPV due to canalith particles in the semicircular canal. A negative test suggests we should perform orthostatics and re-consider other causes.
Objective 3
Perform the HINTS exam to identify concerning features in continuous, spontaneous dizziness.
Click “Spontaneous” to reveal that the HINTS exam should be performed to help further differentiate the cause. Click on the play button to link to a video demonstrating the technique for the HINTS exam. This video is 8 minutes. After the video, reiterate that the HINTS exam should be performed only on those patients with acute persistent dizziness and review how to interpret the findings:
- Head impulse
- Catch-up saccades are considered a “reassuring exam” and suggest a peripheral cause
- The absence of catch-up saccades in a patient with continuous dizziness is abnormal and suggests a central cause
- Nystagmus
- Normal if horizontal and unidirectional
- Abnormal if bidirectional, rotational
- Skew test
- Normal if eyes remain fixed
- Abnormal if eyes exhibit disconjugate gaze
Click “HINTS exam” to reveal that ANY concerning HINTS findings suggest a central cause and if ALL HINTS findings are reassuring, it is likely a peripheral cause like vestibular neuritis or labyrinthitis.
Objective 4
Use a four-step history and physical exam process to differentiate between benign and central causes of dizziness.
Click on each case to reveal the stem of the case and work through it using the TiTrATE format introduced in the framework. At any point, you can click the “Home” button in the top-right corner to return to the algorithm.
Cases
Case 1: BPPV
- Click on the exam to link to a video showing an abnormal Dix-Halpike.
- Discuss management options, which include the Epley Maneuver and Half-Somersault maneuver. Click on the maneuvers to link to a slide with an image depicting how it is performed. Emphasize that in small studies the Epley maneuver has been shown to be more effective, but patients had lower adherence than with the half-somersault. You can refer patients to Vestibular physical therapy for additional treatment.
Case 2: Acute cerebrovascular accident
- Click on the exam to link to a slide showing an abnormal HINTS exam. Navigate through the slide by clicking on the boxes with a cursor and return to the case by clicking the large blue arrow in the top-left corner.
- Briefly discuss that management includes emergent imaging with non-contrast CT, MRI/MRA, antiplatelets and statin. Depending on the time course, patient factors and local resources, this may be managed with TPA or thrombectomy.
Case 3: Vestibular neuritis
- Click on the exam to link to a slide showing a normal HINTS exam. Navigate through the slide by clicking on the boxes with a cursor and return to the case by clicking the large blue arrow in the top-left corner.
Discuss that management for vestibular neuritis typically includes antiemetics and anticholinergics. Steroids are often offered for vestibular neuritis, but share with the learner that the primary research comes from small trials with weak outcome measures (for example, looking at caloric recovery and not at quality of life measures). Learners will often ask at this point if steroids are indicated for acute idiopathic hearing loss and the answer should be yes.
Printouts
coming soon
Interactive Boards
For Teaching
Use for Presenting – there is less text and fewer pop-ups
Take Home Points
- Using Timing and Triggers to narrow the differential for acute dizziness simplifies the next steps for the bedside exam to determine concern for a central process.
- The Dix-Halpike maneuver should be performed to differentiate BPPV from other causes in patients presenting with episodic and positionally triggered dizziness.
- The HINTS exam should be employed to evaluate for cerebrovascular events that are time-sensitive and potentially life-threatening in those patients presenting with acute, persistent, vertiginous symptoms.
References
Fishman JM, Burgess C, Waddell A. Corticosteroids for the treatment of idiopathic acute vestibular dysfunction (vestibular neuritis). Cochrane Database of Systematic Reviews. 2011; 5. Art. No.: CD008607. doi:10.1002/14651858.CD008607.pub2
Muncie, HL, Sirmans, SM, James, E. Dizziness: Approach to Evaluation and Management. Am Fam Physician. 2017; 95(3):154-162
Newman-Toker DE, Edlow JA. TiTrATE: A Novel, Evidence-Based Approach to Diagnosing Acute Dizziness and Vertigo. Neurol Clin. 2015;33(3):577-viii. doi:10.1016/j.ncl.2015.04.011
Kattah, J. C., Talkad, A. V., Wang, D. Z., Hsieh, Y. H., & Newman-Toker, D. E. (2009). HINTS to diagnose stroke in the acute vestibular syndrome: three-step bedside oculomotor examination more sensitive than early MRI diffusion-weighted imaging. Stroke, 40(11), 3504-3510.
Spiegel, R., Kirsch, M., Rosin, C., Rust, H., Baumann, T., Sutter, R., … & Mantokoudis, G. (2017). Dizziness in the emergency department: An update on diagnostics. Swiss medical weekly, 147(5152), w14565.
