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Is The Room Spinning? An Approach to Vertigo

By Dr. Jennifer McCormack MD CCFP

SAMP: A 51 year old man presents with several hours of constant dizziness and vomiting. Symptoms worsen with movements of the head or eyes, but are also present at rest. List 4 features on history or physical examination that would be concerning for a central cause of vertigo.

(Answers at the end of the post!)

CMAJ June 2020 included a clinical review on the diagnosis of BPPV and Vestibular Neuritis. Here are the quick hits:

Pitfall: Don’t use the Dix-Hallpike Maneuver on patients with continuous vertigo symptoms

  • Only perform this maneuver on patients whose episodes of vertigo last less than 2min, and have no nystagmus at rest.

  • Note that most types of vertigo will be exacerbated by head movements. Even with episodic vertigo, the feeling of nausea can persist, which can be confusing. The key is that BPPV has provoked brief episodes that resolve, and there are no nystagmus present at rest.

Pearl: The “HINTS Plus” exam can help differentiate between a peripheral vs central cause of continuous vertigo

  • The HINTS Plus exam has 4 components: the head impulse test, looking at the type of nystagmus, test of skew, and hearing screen. Check out this video on how to do it properly.

  • The goal is to help differentiate a central cause (cerebellar stroke) from peripheral cause (vestibular neuritis).

  • Interpretation of the HINTS exam:

* hearing loss may occur with other less common peripheral causes such as labyrinthitis or Menieres.

  • ANY central feature on HINTS exam means imaging is indicated. If all 4 peripheral features are present, that suggests Vestibular Neuritis.

  • Pearl: it is better to say “central vs peripheral” instead of “normal vs abnormal” when describing the result of a HINTS exam - the latter causes confusion because an “abnormal” head impulse suggests a benign peripheral cause.

Pitfall: Don’t use the HINTS Plus exam on patients with BPPV (episodic vertigo without nystagmus at rest)

  • This is only indicated for patients with ongoing, constant vertigo and nystagmus at rest. The results are meaningless and confusing when performed on patients with suspected BPPV.

Pearl: Remember red flags

  • Severe headache, neck pain, or other neurologic deficits (weakness, diplopia, dysarthria) should trigger imaging, regardless of the characteristics of their vertigo.

  • Spontaneous vertical nystagmus (not during the Dix-Hallpike test) are also a red flag.

SAMP Answers:

  • Other neurologic findings (examples: diplopia, dysarthria, motor weakness, sensory loss)

  • Any of the following HINTS Plus exam findings: bidirectional nystagmus, NORMAL head impulse test, Vertical skew, hearing loss

  • Severe headache or neck pain (think dissection or intracranial hemorrhage)

  • Altered level of consciousness

  • Spontaneous vertical nystagmus

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