Shake, Rattle, and Roll Evaluation of Tremors and Vertigo

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Shake, Rattle, and RollEvaluation of Tremors and
Vertigo

• Common Ambulatory Topics
• General Internal Medicine
• September 26, 2006
• Lisa Willett, MDJ. R. Hartig, MD

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Outline

• Tremors
• Vertigo

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Outline

• Tremors
• Vertigo
• The Twist
• You need to complete the answer sheets.

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Case 1

• 68 yo ? c/o tremor in the hands. Noticed 6 years
  earlier but now noticeably worse.

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Case 1

• 68 yo ? c/o tremor in the hands. Noticed 6 years
  earlier but now noticeably worse.
• Occurs when she is using her hands can no
  longer write, type, put in contacts.

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Case 1

• 68 yo ? c/o tremor in the hands. Noticed 6 years
  earlier but now noticeably worse.
• Occurs when she is using her hands can no
  longer write, type, put in contacts.
• Tremor causes significant embarrassment and seems
  to be worse in social situations.

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Case 1

• 68 yo ? c/o tremor in the hands. Noticed 6 years
  earlier but now noticeably worse.
• Occurs when she is using her hands can no
  longer write, type, put in contacts.
• Tremor causes significant embarrassment and seems
  to be worse in social situations.
• 1. What is the most likely diagnosis?
• 2. How is it treated?

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Tremor

• Distinguished from other movement disorders by
  the repetitive, stereotyped, movements of a
  regular frequency (and amplitude).
• Involuntary, rhythmic, periodic, mechanical
  oscillation of a body part
• Many classification systems (terms)

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3. Name three types of pathologic tremor.

• _____________
• _____________
• _____________

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Name three types of pathologic tremor.

• Resting tremor
• _____________
• _____________

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Name three types of pathologic tremor.

• Resting Tremor
• Action Tremor
• _____________

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Name three types of pathologic tremor.

• Resting Tremor
• Action Tremor
• Intention Tremor

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Name three types of pathologic tremor.

• Resting Tremor
• Action Tremor
• Intention Tremor

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Action tremors

• Involve the hands most frequently
• Head, Voice, Trunk, Legs, and Lips
• Prevalence 0.4-6
• Benign
• Retire prematurely (15-25)
• 60 people choose not to apply for a job

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4. Action Tremor Differential

• _____________
• _____________
• _____________
• _____________
• _____________

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Action Tremor Differential

• Enhanced physiologic tremor
• _____________
• _____________
• _____________
• _____________

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Action Tremor Differential

• Enhanced physiologic tremor
• Parkinsons Disease
• _____________
• _____________
• _____________

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Action Tremor Differential

• Enhanced physiologic tremor
• Parkinsons Disease
• Adult-onset Idiopathic dystonia
• _____________
• _____________

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Action Tremor Differential

• Enhanced physiologic tremor
• Parkinsons Disease
• Adult-onset Idiopathic dystonia
• Wilsons Disease
• _____________

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Action Tremor Differential

• Enhanced physiologic tremor
• Parkinsons Disease
• Adult-onset Idiopathic dystonia
• Wilsons Disease
• Essential Tremor

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Action Tremor Differential

• Enhanced physiologic tremor
• Parkinsons Disease
• Adult-onset Idiopathic dystonia
• Wilsons Disease
• Essential Tremor

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Action Tremor History

• Age at onset
• Situations
• Rate of progression
• Medications
• Family History
• Habits caffeine, tobacco

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(No Transcript)
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5. What medications?

• _____________
• _____________
• _____________
• _____________
• _____________
• _____________

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What medications?

• Beta-adrenergic bronchodilators
• SSRIs / TCAs
• Prednisone
• Levothyroxine
• Valproate
• Lithium

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Diagnosis (Essential Tremor)

• Purely clinical
• Using tests to exclude other forms where
  appropriate

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Features of Tremors
Table adapted from UptoDate and Louis, E.
Essential Tremor. NEJM 345(12) 888.
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Essential Tremor
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Diagnosis (continued)
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Diagnosis
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Reliable Clinical Criteria for Essential Tremor

• Definite
• Postural tremor of moderate amplitude in at least
  one arm
• Present during at least 4 tasks
• Must interfere with at least one ADL
• Exclude medications, alcohol, thyroid, or other

Louis, E. Essential Tremor. NEJM 345(12) 888.
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Reliable Clinical Criteria for Essential Tremor

• Definite
• Postural tremor of moderate amplitude in at least
  one arm
• Present during at least 4 tasks
• Must interfere with at least one ADL
• Exclude medications, alcohol, thyroid, or other
• Possible
• Tremor of moderate amp, in one arm during four
  tasks or head tremor
• Exclude medications, alcohol, thyroid, or other

Louis, E. Essential Tremor. NEJM 345(12) 888.
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Treatment

• Remove / Reduce exacerbating factors
• Alcohol
• Medications
• Surgery

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6. What medications are used to treat Essential
Tremor?

• _____________
• _____________
• _____________
• _____________
• _____________
• _____________

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What medications are used to treat Essential
Tremor?

• Propanolol
• Primidone
• Gabapentin
• Alprazolam
• Nimodipine
• Theophylline

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First Line Agents

• Propanolol
• Effect thought to occur peripherally
• Selective vs. nonselective ß-blockers
• Minimum dose is 120mg per day

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First Line Agents

• Propanolol
• Effect thought to occur peripherally
• Selective vs. nonselective ß-blockers
• Minimum dose is 120mg per day
• Primidone
• Better than phenobarbital
• Doses up to 750mg per day
• Side-effects are common

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Second Line Agents

• Gabapentin / Topiramate
• 3 trials 2 of 3 trials showed benefit
  (1200-3600mg / day)

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Second Line Agents

• Gabapentin / Topiramate
• 3 trials 2 of 3 trials showed benefit
  (1200-3600mg / day)
• Benzodiazepines
• Prolongs the effect of GABA alprazolam

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Second Line Agents

• Gabapentin / Topiramate
• 3 trials 2 of 3 trials showed benefit
  (1200-3600mg / day)
• Benzodiazepines
• Prolongs the effect of GABA alprazolam
• Calcium channel blockers
• Nimodipine (8 of 15 patients) not nifedipine

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Second Line Agents

• Gabapentin / Topiramate
• 3 trials 2 of 3 trials showed benefit
  (1200-3600mg / day)
• Benzodiazepines
• Prolongs the effect of GABA alprazolam
• Calcium channel blockers
• Nimodipine (8 of 15 patients) not nifedipine
• Theophylline
• Enhance the sensitivity to GABA

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Other therapies

• Botulinum Toxin
• Improved tremor but not function

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Other therapies

• Botulinum Toxin
• Improved tremor but not function
• Surgical Intervention
• Two procedures studied in a randomized
  (unblinded) fashion
• Thalamic stimulation
• Demonstrated improved functioning and reduction
  in tremor

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Back to the case

• Has an action tremor
• With more history certainly essential tremor
• Exclude medications, diet/habit exacerbations
• Trial of medications

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Tremors Conclusions

• Action tremors are common
• Essential tremor is the most common form (but
  dont forget enhanced physiologic!)
• If lt40-50 years of age, consider alternative
• Treat those that have impairment
• Primidone or Propranolol

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Theres more to balance than not falling over
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Case 1

• 54 year old woman complains of dizziness
• Room is spinning
• 7. List your differential diagnosis of vertigo
• Which 3 are the most common?

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Dizzy
2. Vestibular Sensation
3. Proprioception
4. Touch Pressure Sensation
1. Vision
5. Hearing
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Dizzy

• Type 1 Vertigo
• Rotational sensation
• Type 2 Presyncope
• Impending faint
• Type 3 Disequilibrium
• Impaired balance and gait without abnormal head
  sensation
• Type 4 Other

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Most Common Causes of Vertigo

• Benign paroxysmal positional vertigo
• Acute vestibular neuronitis
• Menieres disease (endolymphatic hydrops)

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Other Causes of Vertigo

• Drugs
• alcohol, cocaine, barbituates
• antihypertensives, diuretics, nitroglycerin
• antidepressants, sedatives
• salicylates, aminoglycosides, seizure meds
• Cerebrovascular disease
• Migraine
• Multiple Sclerosis
• Acute labyrinthitis
• Brain tumor!

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Characteristics of Peripheral and Central Vertigo
Chawla Olshaker, Med Clin N Am 2006
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Characteristics of Peripheral and Central Vertigo
Chawla Olshaker, Med Clin N Am 2006
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Case 1

• 45 year old male with vertigo
• Intermittent for 2 months
• Turning in bed and putting on shoes
• Yesterdays episode very severe
• nausea, vomiting, couldnt go to work
• Neuro exam normal
• What do you do next?

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NEJM 1999
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Dix-Hallpike Maneuver

• Right ear down nystagmus
• upbeating (toward forehead)
• torsional component with upper poles of eyes
  beating toward right ear
• Vertigo and mild nausea
• 10 to 15 seconds

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BPPV

• Common 107/100,000, mean 54 yrs
• Benign, lasts seconds to minutes
• Relapsing remitting
• Positional rolling over in bed, looking up and
  bending forward
• Initial onset nausea /- vomiting
• Uncommon antecedents
• head trauma vestibular neuronitis

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Benign paroxysmal positional vertigo (BPPV)

• Calcium carbonate crystals (otoliths)
• normally attached to utriculus
• Dislodge, free floating in posterior
  semicircular canal
• Changes endolymphatic pressure and cupular
  deflection

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Treatment Epley
NEJM 1999
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Case 2

• 53 year old male with vertigo
• Awoke with acute dizziness
• Staggered to bathroom and vomited repeatedly
• Neuro exam normal except
• Left beating nystagmus in all positions of gaze

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Case 2

• What do you do next?
• Panic
• Stat MRI to evaluate cerebellar hemorrhage
• Stat page neurology
• Dix-Hallpike maneuver
• Head thrust test

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Head Thrust Test

• Patient fixates on target (your nose) 10 degrees
  from center
• Grasp head, apply brief quick turn to neutral
• Eyes should stay fixed on nose, not have catch-up
  saccades
• Repeat
• Sens 54, Spec 100

Medscape.com
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Vestibular Neuritis

• Viral?
• Viral prodrome, household epidemics, Spring
  early summer
• Develops over hours
• Severe for days
• Better over weeks
• Spontaneous horizontal nystagmus
• Imbalance, but able to stand

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NEJM 2003
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NEJM 2003
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Treatment

• Supportive, drugs decrease severity
• Meclizine (Antivert)
• Transdermal scopolamine
• Promethazine (Phenergan)
• Dimenhydrinate (Dramamine)
• Suppress nystagmus with fixations of gaze
• Balance exercises
• No data to support steroids/acyclovir

Baloh, NEJM 2003 3481027-32 Hain,
Neuro Clin 200523831-853
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Case 3

• 55 year old male with vertigo
• Intermittent x 1 month, minutes to hours
• Becoming more frequent and more severe
• Ringing and fullness in right ear
• Cant hear telephone on right side
• Treated with antibiotics for otitis media
• Last night, vertigo, nausea, vomiting x 2 hours
• Neuro exam normal

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Meniers disease(Endolymphatic hydrops)

• List the 3 components for the triad
• ___________________________
• ___________________________
• ___________________________

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Meniers disease(Endolymphatic hydrops)

• List the 3 components for the triad
• Hearing loss
• Tinnitus
• Vertigo

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Menieres

• Etiology unknown
• Rupture of membranous labyrinth and mixing of
  perilymph with endolymph with vestibular hair
  cell dysfunction
• Can be permanent

Normal
Dilated membranous labyrinth
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Menieres Treatment

• Medical
• Low salt diet
• Triamterene/HCTZ
• Surgical
• Endolymphatic sac surgery
• Labyrinthectomy (chemical variant, gentamycin)
• Vestibluar nerve section

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Vertigo Pearls

• Peripheral
• Severe
• Sudden onset
• Seconds to minutes
• Positional
• Fatigable

• Central
• Mild
• Gradual
• Weeks to months
• Not positional
• Not fatigable
• Associated neurological deficits

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Neuroimaging

• Neurological signs or symptoms
• Cerebrovascular risk factors
• Progressive unilateral hearing loss

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Vertigo Pearls

• BPPV
• positional, Dix Hall-pike ? Epley
• Vestibular neuritis
• post-viral without hearing loss, horizontal
  nystagmus in all directions, vomiting, unsteady ?
  symptomatic care
• Menieres
• vertigo, tinnitus, hearing loss ? low salt,
  diuretics, ENT evaluation

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Remember others

• Drugs
• alcohol, cocaine, barbituates
• antihypertensives, diuretics, nitroglycerin
• antidepressants, sedatives
• salicylates, aminoglycosides, seizure meds
• Cerebrovascular disease
• Migraine
• Multiple Sclerosis
• Acute labyrinthitis
• Brain tumor