An Approach to Vertigo

An overview of how to approach a patient presenting with vertigo, including a discussion and demonstration of the HINTS exam.
Thanks to folks on Twitter for providing feedback on the diagnostic algorithm!
#vertigo #dizziness #HINTS

[@StrongMed]

Welcome to my new subscribers, including those who found me in the past week from my coronavirus video! If you are hoping for more coronavirus news, I'll be posting a follow-up video in a few days.

[@drameerhussain]

Sir.... Please make a video on nystagmus too....

[@S.Clause]

I thought vertigo was a fear/dizziness of/at heights. Please expound.

[@angelavill]

Sir, thank you for this video. I am really having a hard time learning ENT concepts due to the amount of information we are equired to read. The approach is straight forward and very helpful.

[@BrittanyErvin]

​@@drameerhussain😅😊😊v 😊

[@BrittanyErvin]

​@@S.Clause😊😊😊

[@Apolloneus]

I've never had such a good understanding about vertigo than after seeing this video. Thank you, kind sir !

[@leonidkaradzinov3226]

Best video ever! Thank you Dr. Strong!!

[@nusaibahibraheem8183]

Thank you so much for all your videos, but specifically these approach to videos, yours are one of the only few places we can find actual practical approach, it seems everyone just assume we will learn it in the hospital, yet I mostly feel clueless when am there because theory is very different from what is done in practice.

[@serseriherif9530]

I keep coming back to your videos, they are amazing

[@lexandliv]

Thanks! Excellent demonstration of HINTS exam!

[@1Point6One8]

These videos are very helpful Doctor. Bless you for the time and effort you put in. Greetings from Mauritius

[@sjayveenth]

The goat of medicine

[@violetabedranrocha3686]

I love how you structured this! Great lecture!

[@nhbmk]

Another great video! Very helpful diagnostic algorithm. Thank you!

[@tamemomar5724]

You are just so amazing. Can't thank you enough.

[@eugenias471]

thank you so much for this clear and straight forward explanation!

[@sunving]

thanks Doctor Strong, It is very informative lecture. I learn new thing that i never heard of HINT exam so cool.

[@BJPdarkhistoryINDIA]

Great work as always, incredible teaching

[@lifeisgood628]

Now this is some top tier quality material!!!!

[@sunving]

Thank you Doctor Strong and Merry Christmas. I will watch again about HINTS exam, strange that I never learned this on those years, never heard,.

[@StrongMed]

And a Happy New Year to you too!

[@GABHU]

Super clear and concise. Thanks!

[@onlinevoice195]

Very clearly explained. Many thanks.

[@faraz1231]

That was just wonderful!

[@shuvoislam8104]

fantastic synchronization, well done

[@NAV866]

Great lecture. Thank you!

[@dewalmani]

Beautifully explained sir. 👏👏

[@laorence9215]

This is really good. Thanks for this!

[@rohankapur3845]

Another great video! I have great difficulty in distinguishing vertigo from lightheadedness in my patients- I usually ask them what they were doing when the sensation came along and can usually rule out vasovagal syncope, orthostatic syncope and situational syncope. But I'm always worried about a cardiogenic syncope in patients complaining of dizziness coming on spontaneously and find it very hard to not order further cardiac work up. Any tips?

[@4tich770]

UNO DE LOS MEJORES VIDEOS DE VERTIGO MUY COMPLETO , GRACIAS DR STRONG

[@StrongMed]

¡Gracias! Me alegra que te guste.

[@ellenbaker3782]

I have a couple questions as a follow-up to this extremely informative video: 1) will central vertigo ever be episodic, or or if it comes and goes can I be pretty certain it's peripheral? 2) do you have a concise description for an abnormal dix Hall pike? (Does any nystagmus indicate a positive test, or do different directions mean differing things?) 3) With a NORMAL dix Hall pike but episodic vertigo and normal neuro exam, would this suggest non-BPPV peripheral vertigo? Thanks!!

[@fridaatallah8301]

Thank you so much! That was extremely helpful. Just wanted to ask you about the reference. Where can I find these algorithm diagrams and tables?

[@MarkoCetkovic_]

GREAT! Thank you !

[@Owmed]

This is gold!

[@Tagmose89]

Good video ! A few comments - the notion that a clinician reliably can distinguish between lightheadedness (presyncope) , vertigo and unbalance has largely been put into doubt by Kerber et al and Newman-toker, and edlow. One may be more probable than the other , but one should be vary to rely to much on this part , as there is a big overlap . More important is the focus on triggers and timing (TITRATE or ATTEST method ) - The section on (true) vertigo could possibly become even better if it was put into the categories suggested by Edlow and others : tEVS, sEVS and AVS - I would emphasize to do the nystagmus test of the HINTS first . If you do not se nystagmus , you’re done and cannot move in in the HINTS as it should only be carried out on AVS patients with spontaneous / gaze evoked nystagmus . Otherwise the HIT will be always false-negative (indicating central cause)

[@guptarahul87]

Awesome lecture.

[@mohammedseifelnasr9166]

Great informative video.

[@Kalemalex]

Thank you doctor

[@drkassamyify]

Excellent presentation thx

[@BJPdarkhistoryINDIA]

Wonderful lecture, thanks

[@drfareeda3486]

Fantastic dr Strong

[@neelsnehal3501]

Great sir.. Thanku so much!!

[@eniotanaka2229]

Thanks a lot. You helped me a lot

[@alongr5]

Thank you

[@shirinaminoroaya3171]

perfect as always

[@Imusama90]

Thank you so much ❤ ❤ ❤

[@stakeoutrockhound523]

OK, so at a former job, I used to spend hours with my head positioned diagonally, being that I'm tall and have a long neck. The chair was not adjusted to my height. Often I would get dizzy and have a hard time keeping my balance once I left the office and during the break. Perhaps using earphones and taking collagen worsened it. I tried the Epley and Hallpike technique and it seemed to work somewhat.

[@cmhmck]

Does the saccade or lack thereof during the head impulse test only apply to those with baseline nystagmus?

[@prudhvi73]

Hi... Can we get the slides of the presentations??

[@abderrazzakelomari2057]

Hello eric thank you .. 26 sec after upload of the video :)

[@waleedkhalid6908]

nice work

[@PhilipposACosta]

Few years ago, you asked which format do we like the best. At that time, I said you standing in front of the text. You said there were some technical issues to solve first to do this way. Few months later you started doing this format. I always wonder if I had any influence in that. You are the Best Eric Strong

[@testuser2709]

i’m curious, (and i’m obviously not looking for medical direction, but just curious) - i used to sometimes get a dizzy (vertigo) sensation when i got up from being seated a few hours. if i ignored it, it’d go away really quick. but, if i took a breath, and stretched, it’d lead to a near faint. i figured as long as i made sure i was leaning back toward the seat, it was fine - and i enjoyed the momentary high. i was thinking about it while watching the video and it hasn’t happened in a good 10 years, but againl (so from roughly age 16-27), i enjoyed the high, so kinda curious what may’ve caused this/made it disappear.

[@testuser2709]

@ass it’d happen when I stood up, I’d experience an almost faint - it’d happen when I got up and took a deep breath and stretched - if I wanted it to not happen I’d just sit back down). Head movement/inner ear didn’t seem to impact this. it’d last maybe 5 seconds (though that’s hard to judge since I wouldn’t know to look at the time before it came on).

[@stakeoutrockhound523]

@@testuser2709 same here. It could be the tap water of the area you inhabited. Perhaps it was not well filtered. They say tap water can contain female hormones ever since the invention of the pill for the day after.

[@rayhanalupa3944]

Very informative

[@areufkingkiddingme]

How do you differentiate bidirectional and unilateral nystagmus. The pupils go left and right in both cases. Seems awfully subjective in the real world. I’m not sure if I could use this test confidently to rule out central vertigo.

[@mohammadsohrab6400]

Can you please make a video on approach to nystagmus

[@onlinevoice195]

I had vertigo suddenly 2 weeks ago on turning my head in either direction. The physiotherapist said I have BPPV and did a head manipulation for me yesterday. However, my head spinned even more last night when I lied on my bed. The spins were larger than the spins before the head manipulation. What went wrong?

[@StrongMed]

I'm very sorry about how you are feeling, but unfortunately I can't provide specific, individualized medical advice on here.

[@thischannelhasmoved8086]

👍

[@maleknoser6356]

❤❤❤❤❤❤❤❤ great 👍

[@rupendrasinghbhatia4398]

Great video,but you could have added MTLE , presenting as recurrent vertigo of short durations .

[@olivertranton324]

To Pros and Cons. First the con: confusing me with initially claiming an abnormal HINTS suggests peripheral cause but later contradicting it. Pros: Everything else, esp. the short exam demos :)

[@Reziac]

I get Ménière's symptoms _directly_ associated with inadequate thyroid replacement (in fact I can make it come and go by altering dosage). My mom has the same. There is an associated hearing loss as if my ears are full of water (everything is unpleasantly loud but indistinct), accompanied by tinnitus and increased blood pressure. All of this goes away when thyroid dosage is correct. (MRI was negative.)

[@StrongMed]

I hadn't previously heard of an association between symptoms of Meniere's and control of hypothyroidism, but a literature search just found this: www.ncbi.nlm.nih.gov/pubmed/27437251. Thanks for your comment!

[@Marduk-05]

So how do I get rid of it?

[@StrongMed]

It depends entirely on the cause. Unfortunately, I can't give individualized medical advice on here, and I recommend speaking with your doctor.

[@jingyii95]

I have a question. Can vertigo be cardiogenic?

[@StrongMed]

I don't want to say no because somewhere out there is probably a person whose angina or arrhythmia triggered vertigo, but that would be highly unusual.

[@cognitivea]

Best

[@Kareemo227]

Wouldn't it be more appropriate to place vestibular migraines in the vascular territory?

[@StrongMed]

Surprisingly, despite both how common migraines are and the fact that it's 2022, we still don't well understand the pathogenesis of migraines. However, the once popular vascular theory of migraines is no longer considered to be their likely underlying mechanism. From the UpToDate article on migraine pathophysiology: "Cortical spreading depression is hypothesized to cause the aura of migraine, activate trigeminal nerve afferents, and alter blood-brain barrier permeability. Activation of the trigeminovascular system plays a central role in the pathophysiology of migraine, including the onset of neurogenic inflammation, which is linked to the pain of migraine. Sensitization, a process in which neurons become increasingly responsive to nociceptive and non-nociceptive stimulation, is likely responsible for many of the clinical symptoms of migraine."