I`m Dizzy, I Have a Headache, and I Feel Numb

“I’m DIZZY, I have a HEADACHE, and I feel NUMB.”
A Practical Overview of Common Neurological Complaints"
JUSTIN A. MALONE M.D."
NEUROLOGY, INC."
1705 E. Broadway
Suite 280
Columbia, MO
573-449-2141"
Overview"
n  Vestibular
n  Headache
n 
Dysfunction"
Overview"
Numbness"
n 
n 
Central"
Peripheral"
"
Dizziness"
theuppercervicalblog.blogspot.com"
1
Vestibular Symptoms"
Vertigo!
The sensation of self-motion when no self-motion is
occurring or the sensation of distorted self-motion during an
otherwise normal head movement"
Dizziness!
The sensation of disturbed or impaired spatial orientation
without a false or distorted sense of motion"
Unsteadiness!
The feeling of being unstable while seated, standing, or
walking without a particular directional preference"
Oscillopsia!
The false sensation that the visual surround is oscillating"
Presyncope!
The sensation of impending loss of consciousness"
Syncope!
Transient loss of conssiousness due to transient global
cerebral hypoperfusion characterized by rapid onset, short
duration, and spontaneous complete recovery"
International Consensus Definitions for Common Vestibular Symptoms"
Vestibular History"
n 
Neurologists try to help differentiate central
causes from peripheral causes"
n 
Central"
•  Multiple Sclerosis"
•  Stroke"
•  Tumor"
n 
Peripheral"
• 
• 
• 
• 
Benign Paroxysmal Positional Vertigo (BPPV)"
Labyrinthitis: Viral vs. Bacterial"
Meniere’s disease"
General Medical, Non-neurovestibular (Cardiac)"
Vestibular History"
n 
Patient’s difficulty with history"
n 
n 
n 
Description often changes"
Often use the terms “vertigo” and “dizziness” for a
multitude of complaints"
Keys to a successful history"
n 
n 
Focus on dizziness Timing on Triggers"
Not on dizziness type"
2
Vestibular History"
“What do you mean by dizzy?”"
“Does anything bring on your symptoms?”"
n  “Describe exactly how you feel and what you
are doing when these symptoms occur?”"
n  “How long do the symptoms last?” "
n 
n 
n 
Seconds, Minutes, Hours, Days, Weeks"
“How often do the symptoms occur?”"
n  *Always check orthostatic blood pressure"
n 
“Timing-and-Triggers” Approach"
n 
1. Acute, spontaneous,
prolonged vestibular
symptoms (acute vestibular
syndrome)"
n 
•  Vestibular migraine"
•  Meniere’s"
•  TIA"
•  Vestibular neuritis"
•  Posterior fossa stroke"
"
n 
2. Episodic, positional
vestibular symptoms"
3. Episodic, spontaneous
vestibular symptoms"
n 
•  BPPV"
•  Central Mimics"
4. Chronic unsteadiness
(with or without oscillopsia)"
•  Cerebellar degeneration"
•  Bilateral vestibular failure"
•  Spinal cord compression"
Common Causes, Mimics, Duration"
Duration!
Common, Benign Causes!
Principal Dangerous Mimics!
Seconds to hours (episodic:
transient or intermittent)"
Benign paroxysmal positional vertigo(s)"
TIA"
"
Cardiac arrhythmia"
"
Other cardiovascular disorders (eg,
myocardial ischemia, aortic dissection, atrial
myxoma, pulmonary embolus, occult
gastrointestinal bleeding)"
Benign orthostatic hypotension (eg, medications)
(seconds to minutes)"
Reflex syncope (seconds to minutes)"
Panic attack (minutes to hours)"
Meniere syndrome (minutes to hours)"
Neurohumoral neoplasm (eg, insulinoma,
pheochromocytoma)"
Vestibular migraine (seconds to days)"
Days to weeks (nonepisodic:
persistent or continuous)"
Vestibular neuritis"
Brainstem, cerebellar, or labyrinthine stroke"
Viral labyrinthitis"
Bacterial labyrinthitis/mastoiditis or herpes
zoster oticus"
Medication toxicity (eg, anticonvulsants)"
Brainstem encephalitis (eg Listeria, herpes
simplex, paraneoplastic)"
Miller-Fisher syndrome"
Wernicke syndrome"
Medication toxicity (eg, lithium), drug
withdrawal (eg, alcohol), or toxic exposure
(eg, carbon monoxide)"
Continuum, 2012;18(5):1016-1040"
3
Dreaded Nystagmus"
Vestibular Condition!
Test Maneuver!
Nystagmus Duration!
Trajectory/Direction!
Variation in Direction!
Positional Vestibular Symptoms (Episodic Nystagmus Triggered by Specific Positional Maneuvers)!
Posterior canal benign
paroxysmal positional
vertigo (BPPV) (~80-90%
of BPPV)"
"
Head hanging with 45
degree turn to each side
(Dix-Hallpike)"
"
~5-30 seconds"
Upbeat-torsional (torsion
toward downfacing ear)"
Direction reversal typical
on arising from DixHallpike"
Horizontal canal BPPV
(~10-15% of BPPV)"
Supine roll with head
neutral (Pagnini-McClure)"
~30-90 seconds"
Horizontal (toward
downfacing ear much
more than toward upfacing ear)"
Direction reversal typical
during test (when
switching sides or
spontaneously)"
Central paroxysmal
positional vertigo"
Either test position or
midline head hanging"
~5-60+ seconds;
sometimes (ie, remains
while head position is
maintained)"
Downbeat or horizontal
much more often than
upbeat, torsional, or
mixed"
More often direction
invariant; occasionally
shifts trajectory or
direction with head
position"
Continuum, 2012;18(5):1016-1040"
Dreaded Nystagmus"
Vestibular Condition!
Test Maneuver!
Nystagmus Duration!
Trajectory/Direction!
Variation in Direction!
Acute Vestibular Syndrome (Spontaneous Nystagmus That May Be Exacerbated Nonspecifically by Various Head Maneuvers)!
Vestibular neuritis or
neurectomy"
"
Gaze testing (increases
with gaze toward the fast
phase)"
"
Persistent, increases
when visual fixation is
blocked"
Dominantly horizontal +/small vertical or torsional
component"
Direction fixed during first
24-72 hours; occasionally
switches direction during
recovery phase"
Central acute vestibular
syndrome (usually stroke)"
Gaze testing (may
increase with gaze toward
either direction)"
Persistent, may increase
when visual fixation is
blocked"
Dominantly horizontal
much more often than
vertical, torsional, or
mixed"
Acutely ~38% direction
changing with horizontal
gaze position, (mixed
vestibular/gaze holding)"
Continuum, 2012;18(5):1016-1040"
Vertigo"
n  BPPV"
Canalith Repositioning Adapted from the American Academy of Neurology (AAN)
guideline (Neurology 2008;70:2067-2074) regarding recommended use and best
practices for treatment of patients with benign paroxysmal positional vertigo (BPPV).
4
Head-Impulse Test"
n 
Vestibuloocular reflex"
h-HIT (Horizontal Head Impulse Test)"
Most direct way to assess labyrinthine function"
n  Serves to maintain stable visual fixation while the
head is moving, especially with quick movements
where smooth visual pursuit mechanisms can not
keep up"
n  Rapid, passive head rotation from a center to lateral
(10-20 degrees) position (or vice versa) as a subject
fixates at a central target. Technique is important."
n 
n 
Head-Impulse Test"
n 
Vestibuloocular reflex"
n 
n 
Looking for a “refixation saccade”"
Abnormal with:"
•  Labyrinth lesions"
•  Vestibular nerve lesions"
•  Lateral pontine lesions (AICA or MS)"
n 
Paradoxically normal with:"
•  Central lesion"
•  Usually stroke if acute presentation"
n 
Centripetal technique is safer, also not as reliable if
"preexisting extraocular motility abnormality"
Vertigo"
n  Head
Thrust"
PHYS THER Vol. 84, No. 2, February 2004, pp.
151-158
5
Safe-to-Go Bedside Evaluation"
n 
Step 1 History: Plenty of Protective P’s"
If symptoms are old and recurrent:"
"Periodic and Prolonged: recurrent, stereotyped
"episodes or bouts over a protracted period (longer than ~2-4
"years); current episode is typical in all respects."
Plus, if there is vomiting:"
"Proportional Puking: vertigo worse than vomiting
"might be OK; vomiting worse than vertigo is bad"
Plus, if there is loss of conscousness:"
"Prototypical Passing out: classic vasovagal syncope (with
"typical provocation and prodrome) is OK; anything else is
"probably bad"
Continuum, 2012;18(5):1016-1040"
Safe-to-Go Bedside Evaluation"
n 
Step 2 History: Review of Systems: Dearth of
the Deadly D’s"
No Vascular Brainstem Symptoms:"
"Diplopia (double vision)"
"Dysarthria (trouble speaking)"
"Dysphagia (trouble swallowing)"
"Dysphonia (hoarseness/hiccups)"
"Dysmetria (clumsiness)"
"Dysesthesia (facial numbness)"
"Drop Attacks (sudden falls without loss of consciousness)"
"Down-is-up distortions (illusions of room tilt/room inversion)"
Continuum, 2012;18(5):1016-1040"
Safe-to-Go Bedside Evaluation"
n 
Step 2 History: Review of Systems: Dearth of
the Deadly D’s"
No Vascular Inner Ear Symptoms:"
"Deafness (any transient or bilateral hearing loss is bad;
"abrupt-onset unilateral loss may also be bad, but could be
"benign)"
No Cardiovascular Symptoms:"
"Dyspnea (any cardiorespiratory symptoms, unless clearly
"related to vasovagal or panic are bad)"
Continuum, 2012;18(5):1016-1040"
6
Safe-to-Go Bedside Evaluation"
n 
Step 3 Physical Examination: Choose either
“Was Dizzy” or “Still Dizzy” Examination"
Was Dizzy: If symptoms are intermittent or gone, look for benign
paroxysmal positional vertigo (BPPV), orthostasis, or normal
examination and classic history"
P-Power to send patient packing:
"Position-provoked with Positive “Pike”"
"OR"
"Postural with Predictable Pressure Plunge"
"OR"
"Pristine examination and Paradigmatic Presentation (BPPV,"
"vasovagal, migraine, Meniere, or panic attack)"
Continuum, 2012;18(5):1016-1040"
Safe-to-Go Bedside Evaluation"
n 
Step 3 Physical Examination: Choose either
“Was Dizzy” or “Still Dizzy” Examination"
"
Still Dizzy: If symptoms persist, confirm acute peripheral
vestibulopathy by excluding brainstem, cerebellar, and middle ear
signs"
Continuum, 2012;18(5):1016-1040"
Safe-to-Go Bedside Evaluation"
IF SAFE AND CLEAR THEN I’LL SEND HIM ON HOME"
n 
n 
n 
n 
n 
n 
Intact Fields (no visual field cut)"
Stands Alone (can stand
unassisted)"
Face Even (no weakness, droop,
ptosis)"
CLear Enunciation (no dysarthria)"
Accurate Reaching (no drift, normal
rapid alternating movements)"
THErmal Normal (equal pain/temp
sensation)"
n 
n 
n 
n 
n 
n 
Isocoria in Low Light (pupils)"
Straight Eyes (no skew)"
No Deafness (acute change)"
Head Impulse Misses (abnormal
is good)"
One-way Nystagmus"
Healthy Otic and Mastoid
Examination (pearly; no pimples,
pus, perforation, or pain on
palpation of the mastoid)"
Continuum, 2012;18(5):1016-1040"
7
Recurrent Vertigo"
Disorder!
Key Features!
Meniere disease"
Vertigo attacks lasting 20 minutes to several hours with concurrent hearing loss,
tinnitus, and aural fullness. Progressive hearing loss over years"
Vestibular migraine"
Attacks of spontaneous or positional vertigo lasting minutes to days, history of
migraine, migraine symptoms during vertigo, and/or migraine-specific precipitants
provoking vertigo"
Vertebrobasilar TIA"
Attacks of vertigo lasting minutes, often accompanies by ataxia, dysarthria,
diplopia, or visual field defects. Affects older adults with vascular risk factors"
Vestibular paroxysmia"
Brief attacks of vertigo (seconds) several times per day with or without cochlear
symptoms. Responsive to carbamazepine"
Autoimmune inner ear
disease"
Vertigo attacks of variable duration and slowly progressive bilateral hearing loss,
predominantly conductive type"
Otosclerosis"
Vertigo attacks of variable duration and slowly progressive bilateral hearing loss,
predominantly conductive type"
Perilymph fistula"
Vertigo appearing after head trauma, barotrauma, or stapedectomy that is
provoked by coughing, sneezing, straining, or loud sounds. Symptom duration is
variable."
Superior canal dehiscence"
Brief attacks of vertigo induced by loud sounds or pressure in the middle ear.
Autophony occurs in 50% of patients."
Continuum, 2012;18(5):1016-1040"
Recurrent Dizziness"
Disorder!
Key Features!
Orthostatic hypotension"
Brief episodes of dizziness lasting seconds to minutes after standing
up. Relieved by sitting or lying down. Drop of systolic blood pressure
of >20mm Hg after standing up"
Cardiac arrhythmia"
Dizziness lasting seconds. May be accompanied by palpitations. Can
be caused by bradycardia <40/s or tachycardia >170/s"
Panic attacks"
Attacks lasting seconds. Often provoked by specific situations, such as
leaving the house, riding on buses, driving, heights, crowds, elevators.
Accompanied by shortness of breath, palpitations, tremor, heat, and
anxiety"
Drug induced dizziness"
Variable clinical presentation according to pharmacologic mechanism:
sedation, vestibular suppression, ototoxicity, cerebellar toxicity,
orthostatic hypotension, hypoglycemia"
Continuum, 2012;18(5):1016-1040"
Drugs, Dizziness, Imbalance"
Mechanism!
Class of Drugs!
Sedation"
Tranquilizers, neuroleptics, tricyclics"
Vestibular suppression"
Antihistamines, benzodiazepines, anticholinergics"
Ototoxicity"
Aminoglycosides"
Cerebellar toxicity"
Antiepileptics, benzodiazepines, lithium"
Orthostatic hypotension"
Diuretics, vasodilators, antihypertensives, tricyclics, antiparkinsonian"
Hypoglycemia"
Antidiabetics, beta-blockers"
Continuum, 2012;18(5):1016-1040"
8
Chronic Subjective Dizziness (CSD)"
Precipitants"
1.  Vestibular crisis"
2.  Medical Event"
3.  Acute anxiety"
Predisposing Factors"
1.  Introverted
temperament"
2.  Pre-existing anxiety"
Acute Adaptation"
1.  Visual-somatosensory
dependence"
2.  High-risk postural control
strategies"
3.  Environmental vigilance"
Behavioral Comorbidity"
1.  Anxiety disorders"
2.  Phobic disorders"
3.  Depression"
Failure of
Readaptation"
Perpetuating
Loop!
Recovery"
1.  Neurotologic"
2.  Medical"
3.  Behavioral"
Provoking Factors"
1.  Upright posture"
2.  Motion"
•  Self"
•  Environmental"
3.  Visual Demands"
•  Complexity"
•  Precision"
Continuum, 2012;18(5):1016-1040"
Dosing Strategies for CSD"
Medication!
Initial Therapy
Daily Dose (mg)!
Titration (2wk)
Daily Dose (mg)!
Titration (4-6 wk)
Daily Dose (mg)!
Therapeutic Range
Daily Dose (mg)!
Selective serotonin reuptake inhibitors!
Fluoxetine"
5-10"
10-20"
20-40"
20-60"
Sertraline"
12.5-25"
25-50"
50-100"
50-150"
Paroxetine"
5-10"
10-20"
20-40"
20-60"
Citalopram"
5-10"
10-20"
20-40"
20-40"
Escitalopram"
2.5-5"
5-10"
10-20"
10-20"
Fluvoxamine"
25"
25-50 bid"
50-100 bid"
50-100 bid"
Serotonin and norepinephrine reuptake inhibitors!
Venlafaxine"
25-37.5"
37.5-50"
75-150"
75-225"
Milnacipran"
12.5-25 bid"
25-50 bid"
50 bid"
50-75 bid"
Duloxetine"
20-30"
40-60"
40-60"
40-60"
Continuum, 2012;18(5):1016-1040"
Headaches"
migrainechickie.blogspot.com"
9
IHS Classification"
n  Primary
Headaches"
n  Migraine"
n  Tension
Type Headache (TTH)"
Autonomic Cephalgias (TAC)"
n  Trigeminal
n  Other"
n  Secondary"
n  Attributed
to another disorder"
Headache Classification"
Headache Classification"
10
Headache Classification"
Headache Classification"
SNOOP4: Rule out Secondary Causes"
Silberstein SD, Lipton RB. In: Silberstein SD et al, eds. Wolff’s Headache and Other Head Pain. 8th ed. New York: Oxford University Press; 2008:315-­‐377. Dodick D. N Engl J Med. 2006;354:158-­‐165. Bigal ME et al. J Headache Pain. 2007;8:263-­‐272. 11
Headache History"
n 
First two questions to ask patients"
1.  When did your actual headache start?
(acute vs. chronic)"
2.  Have you ever had this same type of
headache before?
"
"
"
"(known headache pattern vs. unusual)"
Headache History"
n 
Headache"
n 
n 
n 
n 
n 
n 
n 
n 
Location"
Quality"
Frequency"
Duration"
Aura"
Associated Sx"
Exacerbating"
Relieving"
n 
Lifestyle"
n 
n 
n 
n 
n 
n 
Sleep"
Hydration/Meals"
Exercise"
Food Triggers"
Analgesic Use"
Depression Screen"
Migraine"
n  ICHD-II
definition"
Migraine is an acute recurrent headache
characterized by episodic, periodic,
and paroxysmal attacks of pain
separated by pain-free intervals"
12
Migraine Prevalence"
Wolff’s Headache 8th ed.
Migraine"
n 
Societal Impact"
n 
n 
Annual U.S. treatment costs est. $1 billion"
$200-$800 per migraine sufferer per year"
•  60% physician visits"
•  30% prescription drugs"
•  1% emergency visits"
n 
Indirect Costs (Lost Productivity)"
n 
Indirect Costs All Headaches"
•  Est. $700-$1200 per patient per year"
•  $20 billion per year "
Migraine"
n  Migraine
without aura"
with aura"
n  Childhood periodic syndromes"
n  Retinal migraine"
n  Migraine with complications "
n  Migraine
13
Migraine"
n  Four
Phases"
n  Premonitory
or Prodromal Phase"
Phase"
n  Headache Phase"
n  Postdrome Phase"
n  Aura
Most patients do not have all four phases"
Migraine Pathophysiology"
Harrison’s Principles of Internal Medicine 17th ed.
Migraine Aura"
n 
Visual"
n 
n 
n 
n 
n 
n 
n 
n 
Scotoma"
Photopsia"
Geometric forms"
Fortification pattern"
Rotation, Oscillation, Shimmering"
Photophobia"
Metamorphopsia"
Macropsia"
14
Migraine Aura"
n 
Sensory"
n 
n 
n 
Motor"
n 
n 
n 
Parasthesias"
Olfactory"
Weakness"
Ataxia"
Language"
n 
n 
Dysarthria"
Aphasia"
Migraine Headache"
n 
Unilateral 60%, Bilateral 40%"
n 
Unilateral often changes sides"
Throbbing"
n  Aggravated by routine physical activity"
n  More frequent in the morning"
n  Gradual onset "
n  Duration 4-72 hours"
n 
Migraine Headache"
n 
Associated Phenomenon"
n 
n 
n 
n 
n 
n 
n 
n 
Anorexia"
Nausea and Vomiting"
Gastroparesis"
Diarrhea"
Photo and Phonophobia"
Lightheadedness or Vertigo"
Blurred vision"
Nasal congestion"
15
Migraine Headache"
n 
Postdrome"
n 
n 
n 
n 
n 
n 
Impaired concentration"
Fatigue"
Irritability"
Muscle achiness"
Anorexia and/or food cravings"
Rare euphoria/refreshed sensation"
Migraine Equivalents"
n 
n 
n 
n 
n 
n 
n 
n 
n 
Scintillating scotoma"
Parasthesias"
Aphasia"
Dysarthria"
Hemiplegia"
Blindness"
Blurring of vision"
Hemianopsia"
Diploplia"
n 
n 
n 
n 
n 
n 
n 
n 
n 
Transient monocular
blindness"
Ophthalmoplegia"
Oculosympathetic palsy"
Mydriasis"
Confusion-stupor"
Cyclical vomiting"
Deafness"
Recurrent Stroke Deficit"
Chorea"
Migraine Treatment"
n 
n 
Accurate diagnosis"
Patient education"
n 
n 
n 
Reassurance"
Expectations"
Lifestyle modification"
Abortive agents"
n  Prophylactic agents"
n 
16
Migraine Treatment"
Trigger Avoidance
n 
Diet"
n 
n 
n 
n 
Hunger"
Alcohol"
Additives"
Foods"
n 
Hormones"
n 
n 
n 
Chronobiological"
n 
n 
n 
Menstruation"
Oral contraceptives"
Sleep"
Schedule"
Stress"
Non-pharmacological Migraine Treatment"
n 
n 
n 
n 
n 
n 
n 
n 
n 
n 
Healthful paTent behavior1 EducaTon1,2 ReducTon of medicaTon overuse2 Smoking cessaTon1 Regular sleeping and eaTng paVerns1-­‐3 Exercise1,3 Biofeedback and behavioral treatment2 Other psychotherapeuTc intervenTons2 PaTent idenTficaTon of triggers3 Headache diary3 1. Dodick DW. N Engl J Med. 2006;354:158-­‐165. 2. Silberstein SD, Lipton RB. In: Silberstein SD et al., eds. Wolff’s Headache and Other Head Pain. 8th ed. New York: Oxford University Press; 2008:315-­‐377. 3. Gallagher RM. Am J Manag Care. 2002;8:S58-­‐S73. Migraine Treatment"
Pharmacological Treatment
n  Based
upon U.S. Headache Consortium
Conclusions and Recommendations"
17
Migraine Treatment NSAIDs"
n 
n 
n 
n 
Aspirin, naproxen, ibuprofren, and diclofenac should
be used for the acute treatment of nondisabling
migraine "
IV or IM Ketorlac should be considered for the acute
treatment of migraine"
Aspirin, Acetaminophen, Caffeine (AAC) should be
used for the acute treatment of migraine"
Isometheptene mucate, dichloralphenazone,
acetaminophen combination should be used for the
treatment of migraine"
"
"*Monitor and educate for medication overuse"
Migraine Treatment Barbiturates"
Butalbital-containing analgesics are not
recommended as a first-line therapy for the
acute treatment of migraine"
n  There is Level-B evidence supporting the
efficacy of these agents in nonspecified
headache syndromes!
n  There is a high risk of dependency,
medication overuse headache, and withdrawal
concerns with these agent."
n 
Migraine Treatment Opioids"
Oral opiate and butorphanol NS are effective
for use in the acute treatment of migraine,
however their use should be limited and
reserved for back up or rescue therapy only
when other medications such as triptans or
NSAIDs cannot be used."
n  There is a high risk of dependency and
withdrawal concerns with these agents."
n  There is no evidence to support the use of
meperidine for migraine"
n 
18
Migraine Treatment Ergots"
Ergots may be considered for the treatment of
selected patients with migraine, although the
magnitude of effect may be modest."
n  Dihydroergotamine (DHE) NS is effective for
the acute treatment of migraine and may be
considered in select patients"
n 
n 
n 
Risk for long term cardiac effects"
High risk of overuse headaches"
Migraine Treatment Neuroleptics and Antiemetics"
n  Metoclopramide
PO or IM is ineffective
as monotherapy for migraine"
n  Chlorpromazine IV and
Prochlorperazine IV should be
considered for migraine"
n  Odansetron and granisetron should not
be considered for migraine"
Migraine Treatment Triptans"
n  Triptans
should be used for the acute
treatment of mild, moderate, and severe
migraine."
n  Combination with naproxen sodium
should be used in the acute treatment of
migraine and offers improved clinical
response over either treatment given as
monotherapy."
19
Migraine Treatment Triptans"
Headache Response!
T-max!
Half-Life!
(2 hours)!
(hours)!
(hours)!
Almotriptan (25mg)"
61%"
2.1"
3.1"
Eletriptan (40mg)"
60%"
1.8"
5"
Frovatriptan (2.5mg)"
44%"
2.5"
26"
Naratriptan (2.5mg)"
48%"
3-5"
6"
Rizatriptan (10mg)"
69%"
2-3"
5"
Sumatriptan (100mg)"
61%"
2"
2"
Sumatriptan (6mg SC)"
80-85%"
2"
2"
Zolmitriptan (2.5mg)"
63%"
2.5"
3"
Zolmitriptan (5mg NS)"
70%"
2.5"
3"
Wolff’s Headache 8th ed."
Migraine Preventative
Treatment"
Frequent headaches (>4 attacks/month)"
Contraindications to, failure with, overuse of,
or intolerance to acute therapies"
n  Patient preference"
n  Frequent, very long, or uncomfortable auras"
n  Presence of uncommon migraine conditions,
including hemiplegic migraine, basilar
migraine, migraine with prolonged aura"
n 
n 
Migraine Preventative
Treatment Antiepileptics"
Carbamazepine
Gabapentin "
n  Lamotrigine
"
n 
n 
n 
n 
n 
Start 25mg, slow titration"
Topiramate
n 
"
"100-600mg"
Start 25mg HS titrate slowly to bid dosing"
Valproate
n 
"600-1200mg tid"
"600-3600mg "
"100-200mg"
"
"500-1500mg/day"
Avoid in women of childbearing age"
Wolff’s Headache 8th ed.
20
Migraine Preventative
Treatment Antidepressants"
n  Tertiary
Amines"
n  Amitriptyline"10-400mg
"start 10mg HS"
"10-300mg "start 10mg HS"
n  Doxepin
n  Secondary
Amines"
n  Nortriptyline"10-150mg
n  Protriptyline"5-60mg
"start "10-25mg HS"
"start "10-25mg AM"
Wolff’s Headache 8th ed.
Migraine Preventative
Treatment Antidepressants"
n  SSRIs"
n  Citalopram
"
n  Escitalopram
n  Fluoxetine
n  Sertraline
n  Some
"
"
"10-80mg ""
"10-20mg"
"10-80mg"
"25-100mg"
may worsen headache"
in patients with depression"
n  Adjuvant
Wolff’s Headache 8th ed.
Migraine Preventative
Treatment Antidepressants"
n 
SNRIs"
n 
n 
n 
Venlafaxine "
"37.5-300mg"
Duloxetine
"
"20-60mg"
Can worsen some headaches"
n 
Other"
n 
MAOIs"
n 
n 
Mirtazapine
Phenelzine
"
"15-45mg"
"
"30-90mg"
•  Note drug and diet precautions"
Wolff’s Headache 8th ed.
21
Migraine Preventative
Treatment ß-blockers"
Atenolol "
Metroprolol
n  Nadolol "
n  Propranolol
n  Timolol "
n 
n 
n 
"50-200mg "BID-QID dosing"
"100-200mg"BID dosing"
"20-160mg "BID-QID dosing"
"40-400mg "BID dosing"
"20-60mg "BID dosing"
Monitor blood pressure and pulse"
Wolff’s Headache 8th ed.
Migraine Preventative
Treatment"
n  Calcium
Channel Blockers"
n 
Verapamil 120-640mgSR "QD-BID dosing"
n 
Flunarizine 5-10mg HS"
n 
Weight gain"
Wolff’s Headache 8th ed.
Migraine Preventative
Treatment others"
n 
Serotonin Antagonists"
n 
Methysergide "
"2-8mg"
"BID-TID"
•  Can not be taken for prolonged periods"
n 
Cyproheptadine
"12-36mg
"BID-TID"
"1.5-3mg
"TID"
•  Useful in children"
n 
Pizotifen
"
•  Weight gain and drowsiness"
n 
Alpha-agonists"
n 
n 
Clonidine
Guanfacine
"
"
"0.05-0.3mg/day"
"1mg"
Wolff’s Headache 8th ed.
22
Migraine Preventative
Treatment others"
n 
Miscellaneous"
n 
n 
n 
n 
n 
n 
n 
Lisinopril
Candesartan
Feverfew
Petasites
Riboflavin
Coenzyme Q
Magnesium
"10-40mg"
"8-32mg"
"50-82mg"
"50-100mg"
"400mg"
"150-300mg"
"400-600mg"
Wolff’s Headache 8th ed.
Chronic Migraine Treatment"
n  FDA
Approval of onabotulinumtoxin type A
(BOTOX)"
n  Migraine
lasting greater than 4 hours per day"
at least 15 days per month"
n  8 of the 15 must have migrainous features"
n  Interfering with quality of life"
n  Headache
•  Family"
•  Work"
•  Social life"
Thunderclap Headache"
n 
Secondary"
n 
Vascular"
• 
• 
• 
• 
• 
• 
• 
n 
Vasospasm"
Aneurysm"
Sinus thrombosis"
Dissection"
Hypertensive crisis"
Stroke"
Hemorrhage"
n 
Primary"
n 
n 
n 
n 
n 
Benign cough"
Sexual (Coital)"
Exertional"
Chiari"
Primary thunderclap"
Other"
•  Cough"
•  Colloid cyst"
23
When Should I Image?"
First or Worst Headache"
Subacute worsening headache"
n  Progressive or new daily
persistent headache"
n  Chronic daily headache"
n  Persistently unilateral headache"
n  Headache not responding to
treatment"
n 
n 
When Should I Image?"
n 
n 
n 
n 
n 
n 
New onset headache in patients with
cancer or HIV"
New onset headache after age 50"
Patients with headaches AND
seizures"
Other symptoms: fever, stiff neck,
nausea, vomiting"
Focal neurological signs or symptoms"
Papilledema, cognitive impairment, or
personality change"
Other Headaches"
n 
More Common"
Migraine"
n  Tension Type/
Musculoskeletal
Headache"
n  Chronic Daily Headache"
n  Medication overuse
headache"
n  Transformed migraine"
n 
n 
Less common"
Trigeminal Neuralgia "
Giant Cell Arteritis"
n  Post concussive
headache"
n  Pseudotumor Cerebri"
n 
n 
24
Numbness"
Drousy Numbness- Maeve Wright"
Neuroanatomy 101"
"
Brain"
Spinal Cord"
Root"
Peripheral Nerve"
Neuromuscular Junction"
Muscle"
"
"
"
"
Sensory Pathways"
25
Anatomy"
n 
n 
n 
n 
n 
Spinal Cord"
Ventral and dorsal rootlets"
Neural foramen"
Mixed spinal nerve"
Dorsal rami"
n 
n 
Paraspinal muscles, skin of neck and trunk with 3-6 level
segmental overlap"
Ventral rami "
n 
Cervical, brachial, lumbar, sacral plexi"
Anatomy"
n 
31 pairs of spinal nerves"
n 
n 
n 
n 
n 
n 
Electrodiagnostically accessible"
n 
n 
n 
n 
n 
n 
8 Cervical"
12 Thoracic"
5 Lumbar"
5 Sacral"
1 Coccyx"
C4-C8"
T1"
L2-L5"
S1-S2"
Cervical exit above vertebral body"
Spinal cord ends at L1-L2"
Netter, Frank H., Anatomy"
n 
n 
n 
Mixed Spinal Nerves"
Plexus"
Peripheral Nerve"
n 
n 
Axon"
Myelin"
Netter, Frank H., The CIBA Collection of Medical Illustrations. 1st. ed. West Caldwell NJ, Wetzel Brothers; 1986
26
Sensation"
n 
Primary Sensory Modalities!
n 
n 
n 
n 
n 
Touch: "
"light or normal (cotton, brush)"
Vibration:
"128 Mhz tuning fork (dorsal column)"
Posistion:
"Toe/Finger Movement (dorsal column)"
Pain: "
"Pinprick (spinothalamic)"
Temperature: "Hot/Cold (spinothalamic)
Sensation"
n 
Cortical Sensory Modalities"
n 
n 
n 
n 
n 
n 
Two point tactile discrimination (index finger 3mm)"
Touch localization"
Stereognosis: identify object by palpation"
Graphestesia: identify numbers written on the skin"
Extinction: Bilateral simultaneous stimulation"
Thumb finding
Sensation"
Upper Motor Neuron vs. Lower Motor Neuron Lesions"
SIGN!
Weakness"
Atrophy"
Fasiculations"
Reflexes"
Tone"
UMN!
Yes"
No* (disuse)"
No"
Brisk*(acute injuries)"
Increased*"
LMN!
Yes"
Yes"
Yes"
Decreased"
Decreased"
27
Sensation"
n 
Central"
n 
n 
n 
n 
n 
n 
Demyelinating"
Stroke"
Tumor/Mass"
Seizure"
Metabolic"
Peripheral"
n 
Neuropathy"
•  Entrapment"
•  Generalized"
•  Diabetic"
n 
n 
Radiculopathy"
Metabolic"
Peripheral Neuropathy"
n 
Subclinical"
n 
Abnormal electrodiagnostic testing"
Focal neuropathies"
n  Diffuse clinical neuropathy"
n 
n 
Distal symmetric sensorimotor"
n 
Autonomic"
•  Classical example diabetes"
Peripheral Neuropathy"
Vinik & Mehrabyan, The Medical Clinics of North America, 88:947-999, 2004
28
Differentiating Sub-types"
n 
Sensory-motor symmetric and length dependent"
n 
Sensory-motor symmetric proximal and distal"
n 
n 
Diabetes, Medications, Toxins, Metabolic, Hereditary"
Diabetic amyotrophy, plexopathy, chronic vasculitic"
n 
Sensory-motor asymmetric"
n 
Sensory symmetric or asymmetric"
n 
Motor symmetric or asymmetric"
n 
Autonomic"
n 
n 
n 
n 
Vasculitic, porphyria, leprosy"
Paraneoplastic, Sjogrens, idiopathic, vitamin B6 toxicity, leprosy"
Motor neuron, multifocal motor neuropathy, poliomyelitis, West Nile"
Usually in the setting of other neuropathies"
85"
Semmes Weinstein Monofiliment"
n 
Valk et al. Muscle Nerve, 20:116-118, 1997"
n 
n 
n 
n 
n 
n 
68 diabetic patients (36M:32F)"
Mean age 52 years"
Duration of diabetes 17.6 years"
Q2-4 week SWM and Neurological assesments"
SWM is reproducible and correlates with neurological exam"
First toe, medial surface, base of third metatarsal"
Loss of sensation at any of the
sites represents
a foot at risk for injury
Aring et al.; American Family Physician, 71:2123-8, 2129-30, 2005
Quantitative Tuning Fork"
n 
Reydel-Seiffer Tuning Fork"
Upper Extremities
Lower Extremities
Age
Values
Age
Values
<40
>6.5
<40
>4.5
41-85
>6.0
41-60
>4.0
>85
>5.5
61-85
>3.5
>85
>3.0
Pestronk et al. Neurology 62(3):461-464
29
Common Focal Neuropathies"
Focal Neuropathies"
n 
Entrapment neuropathies"
n 
n 
Median"
Carpal Tunnel Syndrome"
• 
• 
• 
• 
n 
n 
Anatomic risk"
Repeated undetected trauma"
Metabolic, diabetes and thyroid"
Edema"
“Preacher’s hand”"
Exam"
•  Weak thumb flexion and
opposistion"
•  Senosry loss digits 1, 2, and 3"
•  Tinel’s and Phalen’s signs"
n 
Differential diagnosis C6/7
radiculopathy"
Preston and Shapiro, Electromyography and Neuromuscular Disorders, Newton MA, Butterworth-Heinemann; 1998.
Focal Neuropathies"
Preston and Shapiro, Electromyography and Neuromuscular Disorders, Newton MA, Butterworth-Heinemann; 1998.
30
Focal Neuropathies"
n 
Entrapment neuropathies"
n 
n 
n 
n 
Ulnar"
Cubital tunnel"
“Claw hand”"
Exam"
• 
• 
• 
• 
n 
Weak finger abduction"
Weak thumb adduction"
Weak digit 4 and 5 flexion"
Sensory loss digits 4 and 5"
Differential diagnosis"
•  C8/T1 radiculopathy"
•  Medial cord brachial
plexopathy"
Preston and Shapiro, Electromyography and Neuromuscular Disorders, Newton MA, Butterworth-Heinemann; 1998.
Focal Neuropathies"
Preston and Shapiro, Electromyography and Neuromuscular Disorders, Newton MA, Butterworth-Heinemann; 1998.
Focal Neuropathies"
n 
Entrapment neuropathies"
n 
n 
n 
n 
Radial"
Saturday night palsy"
Radial wrist drop"
Exam"
•  Weak wrist and arm
extension"
•  Weak forearm supination"
•  Weak thumb abduction in
plane of palm"
•  Sensory loss dorsum of arm
and hand"
n 
Differential diagnosis"
•  C5/6 radiculopathy"
•  Upper trunk brachial
plexopathy"
Preston and Shapiro, Electromyography and Neuromuscular Disorders, Newton MA, Butterworth-Heinemann; 1998.
31
Focal Neuropathies"
Netter, Frank H., The CIBA Collection of Medical Illustrations. 1st. ed. West Caldwell NJ, Wetzel Brothers; 1986
Focal Neuropathies"
n 
Entrapment neuropathies"
n 
Femoral"
Motor"
n 
Sensory"
n 
Exam"
n 
•  Diabetic amyotrophy"
•  Lateral femoral cutaneous"
•  Meralgia parasthetica"
•  Weak leg flexion at the hip"
•  Weak leg extension at the
knee"
•  Sensory loss over the thigh
and saphenous distribution"
n 
Differential diagnosis"
•  L2/3/4 radiculopathy"
•  Lumbosacral plexopathy"
Focal Neuropathies"
Netter, Frank H., The CIBA Collection of Medical Illustrations. 1st. ed. West Caldwell NJ, Wetzel Brothers; 1986
Preston and Shapiro, Electromyography and Neuromuscular Disorders, Newton MA, Butterworth-Heinemann; 1998.
32
Focal Neuropathies"
n 
Entrapment neuropathies"
n 
n 
n 
Peroneal"
Foot drop"
Exam"
•  Weak dorsiflexion and
everion"
•  Preserved inversion"
•  Sensory loss lateral leg
and foot"
n 
Differential diagnosis"
•  L5 radiculopathy"
Preston and Shapiro, Electromyography and Neuromuscular Disorders, Newton MA, Butterworth-Heinemann; 1998.
Focal Neuropathies"
Netter, Frank H., The CIBA Collection of Medical Illustrations. 1st. ed. West Caldwell NJ, Wetzel Brothers; 1986
Laboratory Evaluation"
n 
n 
n 
n 
n 
n 
n 
n 
n 
n 
n 
Basic Labs"
Complete Blood Count (CBC)"
Comprehensive Metabolic Panel "
C-Reactive Protein (CRP), High
Sensitivity, Quantitative"
Erythrocyte Sedimentation Rate
(ESR)"
Hemoglobin A1C"
Immunofixation, Serum"
Methylmalonic Acid (MMA)"
TSH"
T4 Free"
Vitamin B12"
n 
n 
n 
n 
n 
n 
n 
!
Extended Labs
Anti-Nuclear Antibody (ANA) titer"
Rheumatoid Factor, Quantitative"
Anti Neutrophil Cytoplasmic
Antibody (ANCA), qualitative"
Fasting 2-hour Glucose Tolerance
Test"
HIV"
History and Exam Dependent"
n 
n 
n 
n 
n 
n 
n 
CSF"
Cryoglobulins"
Hepatitis C Antibody"
Lead, Metals"
Pyridoxine"
Aminolevulinic acid, erythrocyte"
Porphobilinogen deaminase,
erythrocyte"
33
Imaging/Electrodiagnostic
Evaluation of Numbness"
n 
Central!
n 
n 
n 
n 
n 
n 
MRI Brain"
MRI C-spine"
MRI T-spine"
MRI L-spine"
MRI Plexus"
CT-Myelography"
n 
!
Peripheral
n 
n 
EMG"
NCV"
"
Neuropathic Therapeutics"
n 
Capsaicin"
n 
n 
n 
n 
n 
n 
n 
n 
Extracted from chili peppers"
Add one to three teaspoons of cayenne pepper to a jar of cold
cream"
Apply to area of pain"
Prolonged application depletes stores of substance-P"
Wear gloves"
Avoid eyes and genitals"
Initial exacerbation of symptoms with relief in 2-3 weeks"
If possible cover applied area with plastic wrap"
Neuropathic Therapeutics"
n 
Non-targeted therapy"
n 
Insulin"
Lidocaine"
n 
Tramadol"
n 
•  Topical 5%"
•  Local blocks"
•  Centrally acting weak opioid analgesic"
•  Serotonin syndrome (dirty drug)!
34
Neuropathic Therapeutics"
!
n 
Antidepressants"
n 
TCAs "
•  Inhibit reuptake of norepinephrine and
serotonin centrally"
•  Accentuates endogenous pain-inhibition"
•  Dysautonomia and dry mouth"
n 
SSRIs"
•  Duloxetine (SSNRI) "
•  Paroxetine may be beneficial"
Neuropathic Therapeutics"
n 
Antiepileptics"
n 
Carbamazepine"
n 
n 
Phenytoin"
n 
Gabapentin"
•  No efficacy
demonstrated"
•  Positive effect on pain
and quality of life"
•  1800-3600 mg/day"
n 
Pregabalin"
•  DPN"
•  Fibromyalgia"
Lamotrigine"
•  Positive effect on pain"
•  Slow titration (StevensJohnson)"
•  Oxcarbazepine"
•  Lancinating pains"
n 
Topiramate"
•  Fructose analog"
•  Positive effect on pain"
•  200 mg/day maximum
dose"
•  Weight loss"
•  Cognitive decline"
•  Parasthesias"
•  Anhidrosis/Nephrolithiasis"
Summary"
n 
Dizziness"
n 
n 
n 
Headache"
n 
n 
n 
n 
Central v. Peripheral"
H.I.N.T.S"
Acute"
Chronic"
Imaging"
Numbness"
n 
Central v. Peripheral"
35
Common Causes, Mimics, Duration!
Duration!
Common, Benign Causes!
Principal Dangerous Mimics!
Seconds to hours (episodic:
transient or intermittent)!
Benign paroxysmal positional vertigo(s)!
TIA!
!
Cardiac arrhythmia!
!
Other cardiovascular disorders (eg,
myocardial ischemia, aortic dissection, atrial
myxoma, pulmonary embolus, occult
gastrointestinal bleeding)!
Benign orthostatic hypotension (eg, medications)
(seconds to minutes)!
Reflex syncope (seconds to minutes)!
Panic attack (minutes to hours)!
Meniere syndrome (minutes to hours)!
Neurohumoral neoplasm (eg, insulinoma,
pheochromocytoma)!
Vestibular migraine (seconds to days)!
Days to weeks (nonepisodic:
persistent or continuous)!
Vestibular neuritis!
Brainstem, cerebellar, or labyrinthine stroke!
Viral labyrinthitis!
Bacterial labyrinthitis/mastoiditis or herpes
zoster oticus!
Medication toxicity (eg, anticonvulsants)!
Brainstem encephalitis (eg Listeria, herpes
simplex, paraneoplastic)!
Miller-Fisher syndrome!
Wernicke syndrome!
Medication toxicity (eg, lithium), drug
withdrawal (eg, alcohol), or toxic exposure
(eg, carbon monoxide)!
Continuum, 2012;18(5):1016-1040!
Dreaded Nystagmus!
Vestibular Condition!
Test Maneuver!
Nystagmus Duration!
Trajectory/Direction!
Variation in Direction!
Positional Vestibular Symptoms (Episodic Nystagmus Triggered by Specific Positional Maneuvers)!
Posterior canal benign
paroxysmal positional
vertigo (BPPV) (~80-90%
of BPPV)!
!
Head hanging with 45
degree turn to each side
(Dix-Hallpike)!
!
~5-30 seconds!
Upbeat-torsional (torsion
toward downfacing ear)!
Direction reversal typical
on arising from DixHallpike!
Horizontal canal BPPV
(~10-15% of BPPV)!
Supine roll with head
neutral (Pagnini-McClure)!
~30-90 seconds!
Horizontal (toward
downfacing ear much
more than toward upfacing ear)!
Direction reversal typical
during test (when
switching sides or
spontaneously)!
Central paroxysmal
positional vertigo!
Either test position or
midline head hanging!
~5-60+ seconds;
sometimes (ie, remains
while head position is
maintained)!
Downbeat or horizontal
much more often than
upbeat, torsional, or
mixed!
More often direction
invariant; occasionally
shifts trajectory or
direction with head
position!
Continuum, 2012;18(5):1016-1040!
Dreaded Nystagmus!
Vestibular Condition!
Test Maneuver!
Nystagmus Duration!
Trajectory/Direction!
Variation in Direction!
Acute Vestibular Syndrome (Spontaneous Nystagmus That May Be Exacerbated Nonspecifically by Various Head Maneuvers)!
Vestibular neuritis or
neurectomy!
!
Gaze testing (increases
with gaze toward the fast
phase)!
!
Persistent, increases
when visual fixation is
blocked!
Dominantly horizontal +/small vertical or torsional
component!
Direction fixed during first
24-72 hours; occasionally
switches direction during
recovery phase!
Central acute vestibular
syndrome (usually stroke)!
Gaze testing (may
increase with gaze toward
either direction)!
Persistent, may increase
when visual fixation is
blocked!
Dominantly horizontal
much more often than
vertical, torsional, or
mixed!
Acutely ~38% direction
changing with horizontal
gaze position, (mixed
vestibular/gaze holding)!
Continuum, 2012;18(5):1016-1040!
Vertigo!
n  BPPV!
Canalith Repositioning Adapted from the American Academy of Neurology (AAN)
guideline (Neurology 2008;70:2067-2074) regarding recommended use and best
practices for treatment of patients with benign paroxysmal positional vertigo (BPPV).
Safe-to-Go Bedside Evaluation!
n 
Step 1 History: Plenty of Protective P’s!
If symptoms are old and recurrent:!
!Periodic and Prolonged: recurrent, stereotyped
!episodes or bouts over a protracted period (longer than ~2-4
!years); current episode is typical in all respects.!
Plus, if there is vomiting:!
!Proportional Puking: vertigo worse than vomiting
!might be OK; vomiting worse than vertigo is bad!
Plus, if there is loss of conscousness:!
!Prototypical Passing out: classic vasovagal syncope (with
!typical provocation and prodrome) is OK; anything else is
!probably bad!
Continuum, 2012;18(5):1016-1040!
Safe-to-Go Bedside Evaluation!
n 
Step 2 History: Review of Systems: Dearth of
the Deadly D’s!
No Vascular Brainstem Symptoms:!
!Diplopia (double vision)!
!Dysarthria (trouble speaking)!
!Dysphagia (trouble swallowing)!
!Dysphonia (hoarseness/hiccups)!
!Dysmetria (clumsiness)!
!Dysesthesia (facial numbness)!
!Drop Attacks (sudden falls without loss of consciousness)!
!Down-is-up distortions (illusions of room tilt/room inversion)!
Continuum, 2012;18(5):1016-1040!
Safe-to-Go Bedside Evaluation!
n 
Step 2 History: Review of Systems: Dearth of
the Deadly D’s!
No Vascular Inner Ear Symptoms:!
!Deafness (any transient or bilateral hearing loss is bad;
!abrupt-onset unilateral loss may also be bad, but could be
!benign)!
No Cardiovascular Symptoms:!
!Dyspnea (any cardiorespiratory symptoms, unless clearly
!related to vasovagal or panic are bad)!
Continuum, 2012;18(5):1016-1040!
Safe-to-Go Bedside Evaluation!
n 
Step 3 Physical Examination: Choose either
“Was Dizzy” or “Still Dizzy” Examination!
Was Dizzy: If symptoms are intermittent or gone, look for benign
paroxysmal positional vertigo (BPPV), orthostasis, or normal
examination and classic history!
P-Power to send patient packing:
!Position-provoked with Positive “Pike”!
!OR!
!Postural with Predictable Pressure Plunge!
!OR!
!Pristine examination and Paradigmatic Presentation (BPPV,!
!vasovagal, migraine, Meniere, or panic attack)!
Continuum, 2012;18(5):1016-1040!
Safe-to-Go Bedside Evaluation!
n 
Step 3 Physical Examination: Choose either
“Was Dizzy” or “Still Dizzy” Examination!
!
Still Dizzy: If symptoms persist, confirm acute peripheral
vestibulopathy by excluding brainstem, cerebellar, and middle ear
signs!
Continuum, 2012;18(5):1016-1040!
Safe-to-Go Bedside Evaluation!
IF SAFE AND CLEAR THEN I’LL SEND HIM ON HOME!
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Intact Fields (no visual field cut)!
Stands Alone (can stand
unassisted)!
Face Even (no weakness, droop,
ptosis)!
CLear Enunciation (no dysarthria)!
Accurate Reaching (no drift, normal
rapid alternating movements)!
THErmal Normal (equal pain/temp
sensation)!
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n 
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Isocoria in Low Light (pupils)!
Straight Eyes (no skew)!
No Deafness (acute change)!
Head Impulse Misses (abnormal
is good)!
One-way Nystagmus!
Healthy Otic and Mastoid
Examination (pearly; no pimples,
pus, perforation, or pain on
palpation of the mastoid)!
Continuum, 2012;18(5):1016-1040!
Recurrent Vertigo!
Disorder!
Key Features!
Meniere disease!
Vertigo attacks lasting 20 minutes to several hours with concurrent hearing loss,
tinnitus, and aural fullness. Progressive hearing loss over years!
Vestibular migraine!
Attacks of spontaneous or positional vertigo lasting minutes to days, history of
migraine, migraine symptoms during vertigo, and/or migraine-specific precipitants
provoking vertigo!
Vertebrobasilar TIA!
Attacks of vertigo lasting minutes, often accompanies by ataxia, dysarthria,
diplopia, or visual field defects. Affects older adults with vascular risk factors!
Vestibular paroxysmia!
Brief attacks of vertigo (seconds) several times per day with or without cochlear
symptoms. Responsive to carbamazepine!
Autoimmune inner ear
disease!
Vertigo attacks of variable duration and slowly progressive bilateral hearing loss,
predominantly conductive type!
Otosclerosis!
Vertigo attacks of variable duration and slowly progressive bilateral hearing loss,
predominantly conductive type!
Perilymph fistula!
Vertigo appearing after head trauma, barotrauma, or stapedectomy that is
provoked by coughing, sneezing, straining, or loud sounds. Symptom duration is
variable.!
Superior canal dehiscence!
Brief attacks of vertigo induced by loud sounds or pressure in the middle ear.
Autophony occurs in 50% of patients.!
Continuum, 2012;18(5):1016-1040!
Drugs, Dizziness, Imbalance!
Mechanism!
Class of Drugs!
Sedation!
Tranquilizers, neuroleptics, tricyclics!
Vestibular suppression!
Antihistamines, benzodiazepines, anticholinergics!
Ototoxicity!
Aminoglycosides!
Cerebellar toxicity!
Antiepileptics, benzodiazepines, lithium!
Orthostatic hypotension!
Diuretics, vasodilators, antihypertensives, tricyclics, antiparkinsonian!
Hypoglycemia!
Antidiabetics, beta-blockers!
Continuum, 2012;18(5):1016-1040!
Chronic Subjective Dizziness (CSD)!
Precipitants!
1.  Vestibular crisis!
2.  Medical Event!
3.  Acute anxiety!
Acute Adaptation!
1.  Visual-somatosensory
dependence!
2.  High-risk postural control
strategies!
3.  Environmental vigilance!
Predisposing Factors!
1.  Introverted
temperament!
2.  Pre-existing anxiety!
Behavioral Comorbidity!
1.  Anxiety disorders!
2.  Phobic disorders!
3.  Depression!
Failure of
Readaptation!
Perpetuating
Loop!
Recovery!
1.  Neurotologic!
2.  Medical!
3.  Behavioral!
Provoking Factors!
1.  Upright posture!
2.  Motion!
•  Self!
•  Environmental!
3.  Visual Demands!
•  Complexity!
•  Precision!
Continuum, 2012;18(5):1016-1040!
Dosing Strategies for CSD!
Medication!
Initial Therapy
Daily Dose (mg)!
Titration (2wk)
Daily Dose (mg)!
Titration (4-6 wk)
Daily Dose (mg)!
Therapeutic Range
Daily Dose (mg)!
Selective serotonin reuptake inhibitors!
Fluoxetine!
5-10!
10-20!
20-40!
20-60!
Sertraline!
12.5-25!
25-50!
50-100!
50-150!
Paroxetine!
5-10!
10-20!
20-40!
20-60!
Citalopram!
5-10!
10-20!
20-40!
20-40!
Escitalopram!
2.5-5!
5-10!
10-20!
10-20!
Fluvoxamine!
25!
25-50 bid!
50-100 bid!
50-100 bid!
Serotonin and norepinephrine reuptake inhibitors!
Venlafaxine!
25-37.5!
37.5-50!
75-150!
75-225!
Milnacipran!
12.5-25 bid!
25-50 bid!
50 bid!
50-75 bid!
Duloxetine!
20-30!
40-60!
40-60!
40-60!
Continuum, 2012;18(5):1016-1040!