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Dizziness and vertigo-NICE guidance summary

Refer to be seen within 2 weeks if they had -New onset blackout 
( TLOC ) which are suggestive of epileptic seizures ie

○ bitten tongue
○ head turning to one side during TLOC
○ no memory of abnormal behaviour seen before , during or after TLOC
○ unusual posturing
○ prolonged limb -jerking the guidance reminds that brief seizure like activity can often occur during uncomplicated faints
○ confusion following the episode
○ prodromal dejavu ( this is an intense sensation that what is happening for the 1st time has happened before ) or jamais vu ( a feeling of lack of familiarity that what should be familiar is happening for the 1st time )

The following characteristics in the presentation should prompt you to consider a diagnosis other than epilepsy

○ prodromal symptoms that previously stopped on sitting or lying down
○ sweating before the episode
○ prolonged standing that appeared to precipitate the TLoC
○ pallor during the episode

 

Vasovagal syncope even with brief jerking of the limbs- does not 
require referral.

 

Consider a diagnosis of uncomplicated faint / uncomplicated vasovagal syncope if no features to support an alternative diagnosis
 features as 3 Ps which support a diagnosis of uncomplicated faint as
1 posture – prolonged standing or similar episodes that have been prevented by lying down
2 provoking factors – as pain or a medical procedure
3 prodromal symptoms as sweating or a feeling of warm ./ hot before the TLOC episode

 

Situational syncope an alternative diagnosis is not suspected syncope was & is consistently provoked by situations as straining during micturition
( usually when standing ) or coughing , swallowing

 

The patient is seen by a HCP but not a GP –they should take a copy of the patient report form and the ECG to GP the HCP should inform about the diagnosis to GP directly if ECG has not been done the GP should arrange an ECG within 3 days

 

New onset dizziness and a focal neurological deficit as vertical or rotatory nystagmus new onset unsteadiness new onset deafness Check and treat for hypoglycemia if 
known diabetic The patient is not diabetic or treating hypoglycemia does not resolve symptoms
 and the presentation not consistent with
 BPPV or postural hypotension

REFER IMMEDIATELY TO EXCLUDE POSTERIOR CIRCULATION STROKE IN LINE WITH NICE GUIDANCE ON STROKE AND TIA IN OVER 16s

 

Do a HINTS test
 has been developed as a means of assessing patients with acute vestibular syndrome ( AVS ) includes three examinations
1 head impulse test ( HI )
2 characterization of spontaneous nystagmus (-N-)
3 test of skew (-TS )

Each of the three components is analyzed separatel and a finding in keeping with central vertigo on any component of the test indicates the need for neuroimaging

It should be kept in mind that the HINTS exam has been shown to have a greater sensitivity than neuroimaging in ruling out stroke in patients presenting with AVS and outperforms other commonly used stroke risk stratification

 

Adults with transient rotational vertigo on head movement -if local expertise is not available refer in accordance with local pathways Dix-Hallpike maneuver is the gold standard for diagnosis of BPPV Do not perform DHM in patients with neck pathology where the movements involved could be potentially dangerous & in other situations as
○ vertebrobasilar insufficiency and carotid sinus syncope
○ acute neck trauma
○ cervical disc prolapse Offer repositioning manoeuvre as Epley’s if no unstable cervical spine disease and a trained professional is available

 

Vestibular migraine -consider in those who have episodes of dizziness that last between 5 minutes and 72 hrs with a h/o recurrent headaches also known by other terms as migrainous vertigo or migraine-associated vertigo it can be very common and data suggests that VM may affect 1 to 3 % of patients seeking treatment for dizziness
 criteria for VM have been developed by the International Headache Society and include
○ at least 5 episodes of vestibular symptoms of moderate or severe intensity lasting 5 mins to 72 hrs
○ a current or previous h/o migraine attacks with/ without aura
○ 1 or more of the following with atleast 50 % of vestibular episodes

Headache with atleast 2 of
- one sided location
- pulsating quality
- moderate or severe pain intensity
- aggravation by routine physical activity

Photophobia or phonophobia
Visual aura The headache is not accounted for by another vestibular or ICHD diagnosis.

 

Recurrent dizziness -in those adults who have been diagnosed with a functional neurological disorder by a specialist -recurrent dizziness does not need a re-referral unless there are new neurological signs functional neurological disorders is a condition in which people experience neurological symptoms in the abscence of any identifiable causative or structural abnormality advise such adults that their dizziness will fluctuate and may increase during times of stress

 

Dizziness with altered consciousness –Adults with recurrent fixed- pattern
 dizziness associated with alteration of consciousness should be referred for assessment of epilepsy in line with NICE guidance on epilepsy

REFERENCES

  1. Quimby, Alexandra E et al. “Usage of the HINTS exam and neuroimaging in the assessment of peripheral vertigo in the emergency department.” Journal of otolaryngology – head & neck surgery = Le Journal d’oto-rhino-laryngologie et de chirurgie cervico-faciale vol. 47,1 54. 10 Sep. 2018, doi:10.1186/s40463-018-0305-8
  2. Suspected neurological conditions : recognition and referral NICE guideline 127 May 2019 Recommendations for adults aged over 16 | Suspected neurological conditions: recognition and referral | Guidance | NICE
  3. What is Vestibular Migraine ? Nina Riggins , MD , PhD American Headache Society AHS-First-Contact-Vestibular-Migraine-.pdf (americanheadachesociety.org)
  4. Baloh RW. Vestibular Migraine I: Mechanisms, Diagnosis, and Clinical Features. Semin Neurol. 2020 Feb;40(1):76-82. doi: 10.1055/s-0039-3402735. Epub 2020 Jan 14. PMID: 31935766. ( Abstract )
  5. Talmud JD, Coffey R, Edemekong PF. Dix Hallpike Maneuver. [Updated 2021 Jul 23]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK459307/

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