Dizziness

Who to refer:

Frail patients over age 65 with dizziness, lightheadedness or vertigo, and who have:

• A need for Multidisciplinary assessment, including falls assessment and/or specialist physiotherapy for Dix-Hallpike test, Epley manoeuvre or vestibular rehabilitation.

• Significant orthostatic hypotension that might require fludrocortisone.
• An uncertain cause of symptoms, or potentially more than one cause of dizziness.

Who not to refer:

• Patients under 65 – please refer to General medicine
• Patients with more complex vertigo, balance disorders or who have additional ENT symptoms please refer ENTADULT.aspx  (red flags for ENT on audiology RefHelp page)
• Patients with straight forward BPPV and no significant falls risk please refer to Audiology.aspx 
• Patients with labyrinthitis or vestibular neuronitis
• Patients thought to be having an acute cerebellar stroke – please discuss with stroke hotline TIA.aspx

Assessment in Primary care:

People often mean different things by the word “dizzy”, and many have more than one type of dizziness.

One approach is to try and assess whether they mean:

1.       Light headedness or presyncope “as if you might faint”

2.       Feeling off balance “as if you might fall”

3.       “A sensation of everything, or yourself, moving or spinning”, often in relation to head movement or change in posture

Many will experience more than one of these sensations, and some feel them all.

Presyncope is associated with Orthostatic hypotension, severe aortic stenosis and arrythmias. Being “off balance” is extremely common, and often relates to musculoskeletal (OA joint deformities, commonly severe bilateral hallux valgus) or neurological problems (peripheral neuropathy associated with visual impairment is particularly debilitating), so a full multidisciplinary falls assessment is needed.

All patients should have:

• Examination
  • Assessment for clinical hypovolaemia or anaemia
  • Pulse check for arrhythmias
  • Auscultation for heart murmurs (in particular aortic stenosis)
  • Lying and standing blood pressure after 10 minutes lying down (ideally quietly, not talking).

• Investigations:
  • FBC, U&Es, Blood glucose (and if a known diabetic, check blood sugar at time of dizzy spells), Vit B12 and folate
  • If significant orthostatic hypotension  despite stopping BP lowering medication please complete an early morning random cortisol;
    • If cortisol level > 300nM adrenal insufficiency unlikely assuming patient is not on glucocorticoid containing medication
    • If cortisol level < 300nM patient requires SST and should be discussed with MOE/endocrinology
• Up-to-date ECG

Other possible investigations:

• Dix-Hallpike HallpikeTest.aspx test to diagnose BPPV
• The HiNTS test (Head impulse, Nystagmus; Test of Skew) can be useful to distinguish between central and peripheral causes of vertigo and guide further investigation, in patients with nystagmus. HiNTS in someone with vertigo is reassuring if they have all of: unidirectional nystagmus (ie fast phase always in one direction); normal test of skew and Abnormal Head impulse (indicating a peripheral rather than central cause). HiNTS is concerning if they have any of :bi-directional nystagmus or abnormal test of skew or normal head impulse test in the context of vertigo^{. (4,5)}

A video and explanation of the HiNTS test can be found in the resources section.

Management in General Practice

BPPV:  Please see BPPV page under Audiology.aspx for diagnosis, management and patient information leaflets

Postural (Orthostatic) hypotension:

Measures are aimed at maintaining adequate cerebral perfusion.

• Reduce or stop blood-pressure lowering medication, aiming for systolic BP 130-140mmHg (see list of drugs under ‘Exacerbating factors’ above).
• Note in patients with supine hypertension and postural hypotension, NICE guidelines recommend treating blood pressure to the level of the standing systolic BP. 
• To ensure adequate hydration – take a large glass of water (400-500ml) before getting out of bed in the morning and ensure liberal fluid intake throughout the day aiming for 2L.
• Elevating the head of the bed at night by 10-20 degrees (10cm) (reduces nocturnal diuresis and fluid loss)
• Counter pressure manoeuvres
• Full length compression stockings and /or abdominal binders are options but can be difficult to put on and may not be well tolerated.
• Avoid straining during bowel movements or performing other Valsalva-like manoeuvres.
• Eating frequent, small meals is often effective in reducing postprandial hypotension
• Patient advice on fluid intake and self help tips can be found Postural hypotension patient leaflet (2).pdf 

References/Resources:

1. https://bestpractice.bmj.com/topics/en-gb/71/aetiology
2. Does my dizzy patient have a stroke? A systematic review of bedside diagnosis in acute vestibular syndrome. Tarnutzer et al; CAMJ 2011 https://www.cmaj.ca/content/cmaj/early/2011/05/16/cmaj.100174.full.pdf
3. Vestibular disorders: pearls and pitfalls. Choi WY, Gould DR. Medscape Seminars in Neurology 2019 https://www.medscape.com/viewarticle/924084_2
   
   HiNTS (Head impulse, Nystagmus, Test of Skew) video (8 minutes):
4. https://www.youtube.com/watch?v=1q-VTKPweuk
5. HiNTs to diagnose stroke in the acute vestibular syndrome. Kattah JC et al; Stroke 2009: https://www.ahajournals.org/doi/epub/10.1161/STROKEAHA.109.551234
6. NHS Lothian patient information Postural hypotension patient leaflet (2).pdf on management of postural hypotension
7. NICE guideline 136: Hypertension in adults summary PDF Aug 2019 https://www.nice.org.uk/guidance/ng136/resources/visual-summary-pdf-6899919517