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PrimaryCareGuidelinesVertigo/Dizziness

Vertigoisdefinedasanillusionofmovement Explorecharacteristicsofsymptoms;examinefornystagmus DoaHallpiketestinallpatientspresentingwithvertigo/dizziness Ateverystage,exploreRedFlagsandreferasnecessary DizzinesswithpresyncopalsymptomsshouldbereferredtoCardiology Onlythecommoncausesofvertigoareincluded Diagnosis:BPPV ClickhereforHallpike RxEpley,if Patientattendswith positionaltestand nystagmus vertigo/dizziness Epleydemonstration consistentwith Posteriorcanal BPPV(up Hallpike positive Vertigolasting< beating 1minand rotational triggeredby Hallpikenegative geotropic) (1) changesinhead position Isthevertigo associatedwith unilateral hearing loss/tinnitus? Yes Yes No Consider VestibularNeuritis (3) Recurrent attacks? Yes

RefertoENT/AVMif: o Anyother nystagmus o Norecoveryafter2 Epleys

ConsiderMeniresdiseaseif vertigolasts<24hours. StartBetahistine16mgmg tdsandrefertoENT/AVM

Vertigolasting 20minutesor more

ConsiderLabyrinthitis(2)

Startvestibularsuppressants forupto72hourse.g prochlorperazine510mgtds. RefertoENT/AVMifno betterafter4weeks Trydietaryavoidance.Ifno improvement,consider prophylaxis egpizotifen0.5mg1.5mg on.Ifnobetterrefer AVM/Neurology RefertoENT/AVMfor aetiologyandmanagement

EpisodicVertigo lastingseconds tohours

Exploremigraine triggers/features

Consider Vestibular migraine(4)

Dizziness/ imbalance provokedby general movement

o Considermultisensoryfactorsinelderly (5) o Uncompensatedperipheralvestibular impairment(6) o Bilateralvestibularfailure:oscillopsia(7) withheadmovement o Centralvestibular(seeRedFlags)

1. Thenystagmusbeatsupwardstorwardstheceilingandistorsional (rotational)totheundermostear(intheHallpikepostion).Seevideo link. Tobeadded 2. Ifsuddenonsetofsignificantunilateralhearingloss:consider steroids60mgdailyfor6days.MRImayberequired.Bestoptionis samedayreferraltoENT. 3. Considervestibularmigraineifvestibularneuritisappearsrecurrent (morethan3episodes) 4. Vestibularmigrainemaypresentwithoutheadaches.Maybe associatedwithbilateraltinnitus,auralfullnessandmuffledhearing. CanmimicMeniresdisease.RefertoAVM/ENTifunsure. 5. Iffallsareasignificantfeature,considertheFallsClinic/Careofthe Elderly. 6. Stopprochlorperazineandcinnarizine.Explorepsychologicalfactors inchronicallydizzypatients. 7. Oscillopsiaisthesensationthatviewedobjectsaremovingor waveringbackandforth,whilstthepatient(especiallythepatient's head)ismoving. References:Awaitingreferences Authors:DrVictorOseiLah,DrPeterWest,Mr.N.Saunders, Mr.S.Watts,MrJBuckland,DrDWhitehead OthersInvolved:CWSENTTask&FinishGroup,WSHTLRMG

REDFLAGS o Firstattackofvertigowithacutesevereheadache (refertoA/Er/oCVA) o Persistentsymptomsfor>1month(referto ENT/AVM) o Nystagmuslasting>48hours(refertoENT/AVM) o Unilateraltinnitus/dyascusis/auralfullness(follow tinnituspathway) o Sudden/fluctuatinghearingloss(followhearing losspathway) o Dysconjugateeyemovements(refertoNeurology) o Posteriorcirculationsymptoms(referto Neurology) o PositiveHallpikeTest,provokingnystagmusbutno symptoms(refertoAVM/Neurology) o Verticalnystagmus(refertoAVM/Neurology) o Cerebellarsigns(refertoNeurology) Thesearepurposefullyveryshortguidelines.Formore comprehensiveinformationpleaseseeguidelineswrittenby DrPeterWest.Clickhere.
Datepublished:05/13Reviewdue:05/15

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