Learning Objectives
- PV can be diagnosed clinically, it should feel worse with head movement
- PV may be treated with medication or with therapy
- Symptoms of PV are rarely associated with other illnesses
History
A 69 year old lady decides to visit the emergency room one weekend because she has had trouble walking. As soon as she got up from her bed, she felt a sense of spinning from the right to the left. She felt nauseated, she vomited, and she needed to crawl to the bathroom. She lied on the floor of her bedroom, and the sense of movement abated. She was unable to recover sufficiently over hours and she was concerned about the severity of the symptoms. She was able to stand and to walk, but with great difficulty. She says she has had trouble seeing, as if everything she sees seems to be moving, or at least that it seems blurred. She denies having injured her head, changes in medicines, or having the symptoms of numbness or weakness.
She has no allergies to medications. She is using citalopram and omeprazole medications. She has a past medical history of depression and gastro esophageal reflux, and she has had a hysterectomy.
There is a family history of stroke in her grandmother at age 81 and heart attack in her father at age 74.
She does not smoke. She has 1-2 glasses of wine each week. She is a retired county social worker.
Review of systems indicates she has not had a fever, or a headache, or trouble swallowing. She has not had chest pain or pressure, palpitations, or trouble breathing. She has not had a rash. There has been some left knee soreness for months. She has not had urinary frequency or changes in the bowel habits. Her mood and her sleeping have been well.
Examination
Her blood pressure is 144/84, pulse 78, temperature 98.7 F. She is alert, a little pale-appearing, and she prefers to keep her eyes closed. Heart sounds are regular without murmurs. Pupillary and funduscopic exam is normal. There is horizontal nystagmus, especially when looking to the left. Eye movements are normal otherwise. There is normal facial sensation, expression, hearing, tongue, palate and trapezius movement. Strength and tone are normal on both sides. Deep tendon reflexes are normal and the toes are downgoing. Sensation to pin and vibration is normal on both sides. Finger nose finger movements are normal. Hell knee shin movements are normal. She needs assistance to walk. The Fukuda marching test shows that she turns to her left. She is unable to tandem walk or maintain her posture during Romberg examination.
Localization and Neuroanatomy
The symptom of dizziness is often hard to describe by patients and poorly taught to medical providers in training. In the English language, dizziness is a nonspecific term that indicates many kinds of symptoms. It may be used to describe the sensation of alcohol intoxication, adverse reactions to medications, the sensation of dehydration, a head injury, low blood pressure, high blood pressure, a symptom that accompanies a headache, a psychological sensation that occurs when looking over the edge of an elevated structure, a sensation of falling, or a sensation of spinning. When dizziness is the complaint, it helps to ask what this means, or at least, to learn the circumstances.
The symptom of spinning or movement in response to movement of the head is a very particular symptom that relates to the vestibular system. Although this may appear clinically severe, it is normally self-limited and easily remedied. If you cannot be sure the symptom is a sense of movement in response to head movement, other causes should be considered.
When discussing a symptom of dizziness with a patient, consider these possible causes:
- Medication side effect
- Recreational drug effect
- Changes in the heart function or cardiac rhythm
- Orthostatic hypotension
- Symptoms related to a headache
- Symptoms related to a psychological disturbance
- Symptoms related to a known neurological illness
- Changes in cerebellar function
- Symptoms related to a metabolic disturbance
- Benign peripheral vertigo (BPV)
- Other disorders of the vestibular system
It should not be necessary to determine if all of these causes are present. Benign peripheral vertigo often is accompanied by particular historical clues, and the examination of the eye movements and the cerebellar function should help to lock down the diagnosis. In particular, patients with BPV should have normal hearing, normal cerebellar function, they may have nystagmus, but the cranial nerve exam should be normal. It is possible you will observe their symptoms worsen with turning their head to one side or to look up. BPV symptoms may be constant or intermittent. They may last for seconds, minutes, hours or days.
Vestibular testing may also support the diagnosis of peripheral vertigo. This is typically helpful in the setting of other vestibular disorders, as it can assess the caloric responses of the vestibular system on both sides. Illnesses such as autoimmune vestibular disease, Meniere’s disease, and acoustic nerve disease would also be evaluated by this kind of testing.
For symptoms that are recalcitrant, or in the case of a medical history suggesting cerebrovascular disease, an MRI of the brain may be helpful. It is rare that a stroke would result in positional dizziness. A stroke would tend to cause clumsiness, ataxia, or other symptoms, and these would not be expected to vary with head movement. At times, it is not certain that there are other causes though, and the MRI of the brain and acoustic nerves may be needed.
Other tests that may be useful in the evaluation of dizziness are complete blood count, electrolyte panel, EKG, orthostatic blood pressure measurement, tilt table testing with cardiac monitoring, and head CT. These tests should not be necessary for evaluating all types of dizziness. Reserve them for the appropriate circumstances.
Treatment
Treatment of BPV may be unnecessary- some patients recover spontaneously. Other cases may be prolonged and treatment is often helpful for speeding recovery. One simple remedy that helps vestibular disorders is dietary salt restriction. This may affect the production of inner ear fluid and cause the vestibular system to be less sensitive to movement. This tends to take a couple weeks to have an effect.
Medications, such as meclizine, dramamine, and scopolamine are also useful. These cause the vestibular system to have less input. They are also used to treat motion sickness symptoms, for example. Hydrochlorothiazide may be useful for chronic symptoms. It may result in decreased salt retention, leading to improvement, as dietary salt restriction does also. Benzodiazepine medication, such as lorazepam and diazepam, may be useful. For long term use, they may be associated with tolerance or withdrawal symptoms, and so they are used sparingly. Medical academies recommend against using benzodiazepine medications for this disorder.
Physical therapy is often helpful for BPV. This may be home exercises, which can be learned by watching videos on the internet, performed in the office by a medical provider, or with the help of a physical therapist. Exercises that are helpful include the Epley maneuver, the Brandt-Daroff maneuver, and sometimes other so-called canalith repositioning exercises.
Review Questions
- The key clinical feature of BPV is that:
a. The patient has a symptom of dizziness
b. The patient’s symptoms of movement sensation are worse with head movement
c. The patient has signs of horizontal nystagmus
d. The patient’s symptoms are intermittent
e. There are symptoms of a sensation of movement - PV may be treated with:
a. Vestibular positioning exercise therapy
b. Meclizine
c. Dramamine
d. Lorazepam
e. All of the above
Symptoms related to PV may include
a. hearing deficits
b. diplopia
c. nausea or vomiting
d. orthostasis
e. tremor