dizziness, vertigo, balance, migraine


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differentiation of dizziness types impoves the effectiveness of treatment to 80%, miraine might be cured with toral relief of symptoms

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dizziness, vertigo, balance, migraine

  1. 1. Vertigo and dizziness : differential diagnostics and individual treatment procedures Trinus K. P.L.Shupyk National Medical Academy for Postgraduate Education, Ukraine, Kyiv
  2. 2. Vertigo - <ul><li>- a disturbance in which the individual has a subjective impression of movement in space (subjective vertigo ) or objects moving around him (objective vertigo ), usually with a loss of equilibrium </li></ul><ul><li>True vertigo is distinguished from faintness, light-headedness, or other forms of “dizziness”, results from disturbance somewhere in the equilibratory apparatus: vestibule, semicircular canals, 8 th nerve,... or eyes. </li></ul><ul><li>The Merck Manuel </li></ul>
  3. 3. Dizziness <ul><li>- distortion of the perception of space and movement . </li></ul><ul><li>Some authors consider distortion of the time perception to be the sign of dizziness . </li></ul>
  4. 4. Vertigo <ul><li>- Illusion of the nonexistent movement : </li></ul><ul><li>more often rotatory , seldom swaying or linear movement forward - backward , aside, up and down . </li></ul>
  5. 5. Dizziness <ul><li>Light-headedness </li></ul><ul><li>Black-outs </li></ul><ul><li>Giddiness </li></ul><ul><li>Numbness </li></ul><ul><li>Faintness </li></ul><ul><li>Confusion </li></ul><ul><li>Claustrophobia </li></ul><ul><li>Syncope </li></ul>
  6. 6. Coordination disorders (disequilibria) <ul><li>– b alance disorder might be without dizziness , indicating presumably lesion of motor systems . </li></ul><ul><li>Patients are complaining of : </li></ul><ul><li>“ I am going like drunkard , swaying , short coordination disturbances , as if being pushed aside ...” </li></ul>
  7. 7. Material and methods <ul><li>During 1983-2003 154 persons have been examined with average age of 34.36±11.23 . </li></ul><ul><li>All the patients have been complaining of vertigo-dizziness attacks during last 5-7 years . </li></ul><ul><li>Vestibular dysfunction has been documented instrumentally by increased of the VestEP peak latencies while somatosensory, acoustic, visual being normal, presence of nystagmus , and also balance disorders of middle level according to cranio-corpography data . </li></ul>
  8. 8. Subjective sensations during caloric test
  9. 9. Nystagmus frequency ( per 1 min .) p = 0,04 (F test)
  10. 10. Nystagmus frequency <ul><li>Nystagmus might be physiological and pathological </li></ul><ul><li>Pathological nystagmus depending from frequency characterize hypo- or hyperreflectivity </li></ul>
  11. 11. Hair cells <ul><li>Type І – big , vase-like , situated compactly in the center of the receptor structure </li></ul><ul><li>Type ІІ – small , cylindrical , dispersed in macula and cupula . </li></ul>
  12. 12. Vestibular nerve <ul><li>Consist of peripheral portion innervating hair cells, vestibular ganglion , where the soma of the bipolar cells are localized and axons, proximally directed from these cells and composing central portion of the nerve . The number of the neurons in the ganglion is 7 . 000 - 18 . 000. Each of peripheral receptors receives approximately equal amount of the fibers . </li></ul><ul><li>The major difference of vestibular nerve from all the other sensory nerves is presence of thick fibers , diameter of which exceeds 5 µ and the number of which reaches 10%. </li></ul><ul><li> Average diameter of the vestibular nerve fibers is 3-4 µ. The fibers are packed in severe order : in the peripheral portion thick fibers are localized centrally , while thin - peripherally . At the ganglion level thick fibers are placed dorsocranially in the central part of the nerve. Soma dimensions correlates with the fiber diameter . For thin fibers the oval-shape neurons with average diameters of the soma 15 and 22 µ are typical , and for the thick ones - 22 and 40 µ. </li></ul>
  13. 13. Vestibular nuclei <ul><li>Thick fibers terminating mostly in the central part of the upper vestibular nucleus , where big neurons are located , vestibulo-ocular by function . </li></ul><ul><li>Terminals of the thin fibers are dispersed in all the vestibular nuclei. </li></ul>
  14. 14. Vestibular pathways <ul><li>Thick fibers of the vestibular nerve participate in the generation of high frequency nystagmus , related to vertigo . </li></ul><ul><li>Dizziness therefore is related to thin fibers. </li></ul>
  15. 15. Vestibulo-cortical pathways <ul><li>Cognition of the sensory information is finalized at the brain cortex . It is proved to be several pathways between vestibular periphery and cortical vestibular zone . </li></ul><ul><li>The shortest one is projecting to the contralateral suprasilvian girus and is characterized with the latency of response in the ranges of 3-5 м s . This pathway is considered to have only two synaptic transmissions . </li></ul><ul><li>Evoked responses recorded from the ipsilateral hemisphere have bigger latency - about 8 м s , and their amplitude depended from the type of narcosis , thus indicating bigger amount of synaptic transmissions. </li></ul>
  16. 16. In physiological conditions <ul><li>Vertigo is initiated by rotations . </li></ul><ul><li>Dizziness is initiated by </li></ul><ul><li>hyperventilation </li></ul>
  17. 17. In pathological conditions <ul><li>Vertigo </li></ul><ul><li>is typical for : </li></ul><ul><ul><li>Cupulolithiasis </li></ul></ul><ul><ul><li>BPPV </li></ul></ul><ul><ul><li>Vestibular neuritis </li></ul></ul><ul><ul><li>Meniere disease </li></ul></ul><ul><li>Dizziness </li></ul><ul><li>is typical for : </li></ul><ul><ul><li>Intoxications </li></ul></ul><ul><ul><li>Chronic diseases </li></ul></ul>
  18. 18. Methods for documentation <ul><li>1. besides Nystagmography </li></ul><ul><li>2. Evoked potentials </li></ul><ul><li>3. Cranio-corpography ( postulography ) </li></ul>
  19. 19. Vestibular lesion <ul><li>EP N vestib acoust visual olfact somatosens </li></ul><ul><li>P1 (40) 118 (60) 40 (60) 55 (140) 135 (80) 72 </li></ul><ul><li>N1 (80) 146 (100) 76 (100) 93 (230) 210 (150) 147 </li></ul><ul><li>P2 (150) 1 78 (180) 150 (180)147 (300) 291 (200) 178 </li></ul><ul><li>Increased latencies of all the peaks of the vestibular EP while the other Eps are normal – indicates central and peripheral vestibular dysfunction . </li></ul><ul><li>Typical for vertigo </li></ul>
  20. 20. Vestibular dysfunction <ul><li>EP N vestib acoust visual olfact somatosens </li></ul><ul><li>P1 (40) 53 (60) 40 (60) 55 (140) 135 (80) 72 </li></ul><ul><li>N1 (80) 96 (100) 76 (100) 93 (230) 210 (150) 147 </li></ul><ul><li>P2 (150) 150 (180) 150 (180)147 (300) 291 (200) 178 </li></ul><ul><li>Increased P 1 and N 1 of the vestibular EP indicate maximal dysfunction in the peripheral, brainstem and subcortical parts of the vestibular system . Typical for dizziness ( for example Chornobyl clean-uppers , 884 persons examined ) </li></ul>
  21. 21. Coordination disturbance <ul><li>EP N vestib acoust visual olfact somatosens </li></ul><ul><li>P1 (40 ) 37 (60) 40 (60) 55 (140) 135 (80) 72 </li></ul><ul><li>N1 (80) 72 (100) 76 (100) 93 (230) 210 (150) 147 </li></ul><ul><li>P2 (150) 148 (180) 150 (180)147 (300) 291 (200) 178 </li></ul><ul><li>Might be not accompanied with vestibular dysfunction according to EP recording </li></ul>
  22. 22. Methods for balance evaluation <ul><li>Balance function is documented with the help of cranio-corpography ( postulography ) </li></ul>
  23. 23. Typical cases of the CCG <ul><li>Left figure – wide undulations during stepping test typical for the central lesions of the lower portion of brain stem </li></ul><ul><li>Right figure peripheral lesion ( right labyrinth ) </li></ul>
  24. 24. Differential diagnostics Disturbance Severe disturbance Small disturbance Balance Might be present High frequency Low frequency Nystagmo graphy Might be normal Increased all latencies Increased latencies of Р1 and N 1 VestEP Typical Clear description Unclear Complaints Balance disorder Vertigo Dizziness
  25. 25. Effect of Tanakan at the symptomatics of vertigo-dizziness, horizontal axis - % of patients, vertical - symptoms
  26. 26. Dizziness <ul><li>In the case of hyporeflexia </li></ul><ul><li>Tanakan </li></ul>
  27. 27. Effect of Cinnarizine at the dizziness -vertigo
  28. 28. Vertigo <ul><li>In the case of hyperreflexia treatment must be in two phases : </li></ul><ul><li>1. Medicaments with sedative activity </li></ul><ul><li>2. After managing hyperreactivity -activation of the plastic processes – drugs with nootropic effect </li></ul>
  29. 29. <ul><li>Vertigo and dizziness originates in the vestibular system; </li></ul><ul><li>The difference in the effect of therapy at vertigo and dizziness (black-outs, lightheadedness) is evident; </li></ul><ul><li>There is no difference in the effect of therapy at dizziness, black-outs, light-headedness etc. </li></ul>
  30. 30. NB! Strict differentiation of the complaints might be the first step for the correct diagnostics and treatment choice .
  31. 31. Complaints distribution
  32. 32. Patient: P. 25 years old, military officer Complaints: intensive headaches without clear localization 1-3 times per week with 1-2 days duration and accompanied with severe vertigo and dizziness , hyperhydrosis, loss of consciousness and vomiting episodes. Labor capacities and quality of life are seriously decreased.
  33. 33. Anamnesis morbi: <ul><li>Start of the disease - August 2001 . After stress and overloading with computer use up to 1 2 - 14 hours per day. </li></ul><ul><li>According to medical documentation presented by the patient has been at the neurological department of the Central Military hospital from January 2002 till July 2003 at the stationary treatment . </li></ul>
  34. 34. <ul><li>Therapy with vascular, nootropic, dehydrative, sedative, analgesic, antimigrainous, desensibilizative, anticonvulsive, imunecorrective, antiviral and hormonal drugs has not given any positive effect, the frequency and intensity of the headache attacks preserved. </li></ul><ul><li>Morphium solution has not presented positive effect. </li></ul><ul><li>In July 2003 patient got II group of invalidity . </li></ul><ul><li>August 2003 has admitted to Neurootological Center. </li></ul>
  35. 35. <ul><li>Basing at the knowledge that migraine attacks have been accompanied with vertigo - dizziness , lack of the effect of previous therapy and objective neurootological data: </li></ul><ul><li>1.    Balance disturbances , </li></ul><ul><li>2.    Positive Takahashi test during ECG recording , </li></ul><ul><li>3.    Micronystagmus present, </li></ul><ul><li>4.    Dominant increase of the latencies of the Vestibular EPs, - </li></ul><ul><li>We have supposed vestibular nature of the headaches described . </li></ul><ul><li>According to IDC 10 principal diagnosis : </li></ul><ul><li>Vestibular dysfunction (H 81). </li></ul><ul><li>Status Migrainosus (G 43.2). </li></ul>
  36. 36. Positive effect of betahistine appeared at the first days of treatment . <ul><li>Intensity and duration of the headaches progressively decreased, vertigo and nausea disappeared, intervals between the attacks – increased. </li></ul><ul><li>By the end of the first month the migrainouse attacks totally disappeared! </li></ul>
  37. 37. Evoked potentials : ( latency of P 1 ) <ul><li>Decrease of the latencies of the EP peaks of all the systems after 1 month of treatment </li></ul><ul><li>Clear normative data after 9 months </li></ul>
  38. 38. Vertigo, dizziness and additional symptoms Medicine of choice betahistine
  39. 39. Differentiated approach to the treatment of vestibular migraine Cinnarizin Dimenhydrinate
  40. 40. Conclusions <ul><li>1. We have the reason to differentiate vertigo , dizziness and disequilibrium </li></ul><ul><li>2. Vertigo and dizziness are generated by the vestibular system </li></ul><ul><li>3. We have not enough evidence to differentiate light-headedness, black-outs, confusion, faintness from dizziness </li></ul><ul><li>4. Vestibular migraine has its own specifics </li></ul><ul><li>5. Localization of the headache might be important for the therapy selection </li></ul>
  41. 41. <ul><li>Pleasant vertigo to everybody ! </li></ul>