Managing Vertigo

40% of people experience vertigo in their lifetime. These simple questions help us know what's causing it and how to provide relief to patients through medications or triaging to the appropriate provider.
 
The GameChanger
Migraine headaches can present as vertigo. Simple questions and recommendations from pharmacists can be lifechanging for these patients.
 
Guest
Sarah Powell, MD
Physician, Surgeon
Ear, Nose, and Throat Consultants

 
Reference
https://entad.org/resources/patient-information-dr-teixido/migraine-management-for-otolaryngologists/

Migraine Handout
Migraine, More Than A Headache


Pharmacist Members,REDEEM YOUR CPE HERE!
 
Not a member? Get a Pharmacist Membership & earn CE for GameChangers Podcast episodes! (30 mins/episode)


CPE Information
 
Learning Objectives
Upon successful completion of this knowledge-based activity, participants should be able to:
1. List three ways patients present with symptoms of vertigo.
2. Describe how to manage patient symptoms with medications or triage to another healthcare provider.

0.05 CEU/0.5 Hr
UAN: 0107-0000-24-158-H01-P
Initial release date: 04/29/2024
Expiration date: 04/29/2025
Additional CPE details can be found here.

Follow CEimpact on Social Media:
LinkedIn
Instagram

Transcript

Speaker 1: 0:08

Hey, ce Plan members From CE Impact, this is Game Changers. Today I have with me a very special guest, dr Sarah Powell, who is an otolaryngologist at Ear, nose and Throat Consultants in Dakota Dunes, south Dakota. She is a special guest because she happens to be my sister. Welcome, dr Powell. Thanks for talking with me today.

Speaker 2: 0:28

Thank you, I'm so excited to finally do this podcast with you.

Speaker 1: 0:32

Yeah, I'm excited too, and from now on I'm going to call you Sarah, because it's going to be weird for me to call you Dr Powell. And I will also say that people say we sound alike. So we were joking before we started recording that we'll be anxious to hear this because you know, when you listen to your own voice you don't sound the same, but we may sound the same. I don't know. You'll have to tell us as listeners, but we have been talking about doing this episode for quite some time. So I'm excited to finally make it happen, because today we're going to talk about vertigo, and I feel like vertigo is one of those frequency illusion things Like when you decide you know you like a certain car and then all of a sudden you see it all the time on the road.

Speaker 1: 1:11

I think there's like a phenomenon like Bader-Meinhof I think it's called. Anyway, because I feel like this is one of those things Like when you start talking about vertigo, people are like oh yeah, I had that. I had that. And in doing a little research for this podcast, I saw one statistic that said that 40% of people will experience some type of vertigo in their lifetime. From your practice, do you think that sounds about right?

Speaker 2: 1:35

I do. I think I'm a little biased in that I see a lot of people with vertigo from a physician or even just practitioner standpoint. It's one of those things that's always really tough because a lot of people, unless you have a very specific way to treat it, just try to avoid it. And so many years ago we actually opened like a vestibular therapy practice as part of my practice here specifically for this, because we see so many people with dizziness and vertigo and if it's not an ear issue that I can specifically treat, I was just at a loss as to what to do with them. So I've kind of amassed quite a following of dizziness and vertigo patients, even to the point where some of my partners like to just send them to me. So it is a topic that is quite familiar to me.

Speaker 1: 2:29

Yeah Well it's a good niche because obviously, if 40% of people are having it, there's a need for it, and that's exactly that's a really good segue, because that's exactly why we started talking about this in the first place, and I thought this is a podcast that we need to do, because I've personally had a couple of scenarios and I've had to kind of just sleuth my way through it, with your help, obviously, and so I always say, like, if you don't have a family member that you can go to for these questions like, how do you really triage and, you know, try to figure out what's actually going on. But there was actually an issue where my husband had some really serious vertigo and we ended up in the ER and then, in talking to you, I ended up at that practice that you're talking about, or I didn't, my husband did, and you know he was able to get on some treatment really quickly, which was helpful because that wasn't the direction the ER was taking us, and I think that we would have had some really long lasting effects of that had it not, you know, had I not talked to you and you said, oh no, he needs to get on steroids right away. So so you know, I think that patients often will go to the pharmacy because they're looking for meclizine or, you know, they're just looking for that quick fix because they have no idea what's going on, and so that's a really good way that pharmacists can triage. And also, I think, in the ER you know, I mean you've even talked about and I'll let you sort of talk about that, but you know that you're trying to do some education to some of the emergency rooms to say, like, ask these questions and then get them here immediately or, you know, get them on a steroid quickly. So I'll let you kind of talk through that.

Speaker 1: 3:58

But I think that's just sort of the background in. You know why we decided to do this and I think it's just a really important topic. So I'll let you kind of get into it. One of the things that you said, I guess just to set it up, is there's really three things that cause vertigo and the questions that you ask and the way that it presents. You can pretty much triage it from that. So talk to me a little bit about what the issues are like, what is the gap in practice that you see and why you've kind of created this niche within your own practice for these patients.

Speaker 2: 4:28

Yeah Well, whenever someone, even in my practice, says something I'm dizzy, I have vertigo, I think the first thing to identify is what does that mean to them? Because dizziness is a huge array of things. So that can be something as simple as I get lightheaded if I stand up too quickly, which directs us more, or blood pressure issues and things like that versus true vertigo, which I mean vertigo really is. If you look at one of the definitions is a disturbed spatial orientation. So that's really what I'm going to focus on today, not lots of other different kinds of dizziness. But when I ask patients, do you feel like your world is moving? It doesn't always have to be spinning. Spinning vertigo really does help us identify an inner ear issue, but just any kind of spatial movement to them is truly vertigo.

Speaker 2: 5:19

One other thing as ENTs, this is kind of a little semantics thing, but vertigo truly is a symptom, it's not a diagnosis. So when people say, oh, I was diagnosed with vertigo, it's like, well, okay, so you have some spinning sensation, but that's not your diagnosis. There's lots of things that can cause it. So when I mentioned those three things, it's the first thing I always ask people is how long does it last, and that puts us into three categories Is it seconds to minutes, is it hours or is it days? And so the easy one is if it's seconds to minutes, you know somebody says and I always ask them too does it happen when you roll over in bed? Does it happen when you reach for something on a shelf? If it's a very intense sensation of spinning? But if you focus on something, sit down, it goes away in a few minutes. That is very classically something called benign paroxysmal positional vertigo, which is a mouthful, so we always just call it bppb, and that is what everyone knows, as it's like crystals or, you know, rocks loose they've all kinds of ways that you can describe it and that's something for people that really can come and go throughout their lifetime.

Speaker 2: 6:29

If somebody has that, it might go away for a while, but it is very likely to come back. Actually, our vestibular therapists have been tracking this. They look at their statistics every year and they see that over time if somebody has had BPDV, it's about a 40% likelihood they're going to have it again at some point. The nice thing is this is the easiest one to treat and these are the ones that if somebody comes in for meclizine or other things. These aren't really things that medications are going to make go away.

Speaker 2: 6:59

It truly is a positioning thing that happens quickly with what are called otoliths in the inner ear, and so they really need to see a physical therapist that is trained, or an ENT, an otolaryngologist, that does these, but somebody that can do what we call some repositioning maneuvers for positional vertigo, and most physical therapists have training in this. This isn't super specific. There are maybe about 10% of patients that it's not the typical positional vertigo. So if they say, oh yeah, I've tried that, then they might need to go more specifically to a true vestibular therapist that knows to check for the other balance canals in the inner ear. But that's the easiest one, and that's people that I really say don't even take the meclizine. It's just going to make you tired and it's not going to change your symptoms.

Speaker 1: 7:46

Yes, and I feel like that's the one where when you say, oh, I've had some vertigo, and it's like, oh, did you go get that maneuver Like that's what people always relate to the most too.

Speaker 2: 7:56

Absolutely, and they say I have those crystals or I have a rocks loose, and that is the most common type, which is great because it is the one that oftentimes it'll go away on its own, or the easiest to treat. So then we move on to. If somebody says well, you know what, I'm going to skip the middle one for now and come back to it. If somebody is dazed, which most of the time, as pharmacists like these are the ones you're going to see end up in the emergency room. Or you're going to have a family member Like these are the ones you're going to see end up in the emergency room. Or you're going to have a family member, you know if you're a community pharmacist or in a pharmacy saying I'm trying to get something for a family member, because these are the people that probably can't get off of their bathroom floor Like it is a true spinning, vomiting. I mean, they are really ill and most of these probably will end up in an emergency room or a doctor's office because it's so intense and they can't really function.

Speaker 2: 8:48

And we always think of, like severe vertigo is when you can't do your activities of daily living, then it needs to be evaluated, and ones like this. They probably do need an evaluation just to rule out more significant things like a stroke and other things like that. But otherwise these are the ones that I mean. Meclosine certainly can be helpful to just calm down that vomiting, any kind of other you know anti emotion sickness, whether it's a patch, a band, something will help so that it just settles a little and they can feel a little bit of relief. But these are the ones that probably need to get into a position to get on some stronger medication.

Speaker 2: 9:28

I think even with your husband who had had this, I had said this is usually a sign of a either what we call a neuritis, which is an inflammation of the vestibular nerve, or a labyrinthitis, which is inflammation of the inner ear nerve, or a labyrinthitis, which is inflammation of the inner ear, but it's always inflammation driven. And so typically we see that if they can get on steroids and even something stronger like a diazepam or lorazepam fairly quickly, that's going to give them some relief. But then it really is a process of recovery to let everything heal and these are the ones that typically will need some vestibular therapy and it's just a process to get better.

Speaker 1: 10:11

So when you say vestibular therapy, I think that was the thing that I didn't really know much about and luckily I'm in a little bit more of an urban area where there are specific people that I could go to. But I remember this happening and you were like oh yeah, you need to get in to someone to to relieve that. So if they're in you know a rural area or like what are the, you know, what are you looking for in that person? It's not a typical physical therapist. I assume that it's a little bit more specialized.

Speaker 2: 10:40

That's exactly it. It's a subspecialty of physical therapy, so and we have a couple and they have a lot of physical therapy students that come through as well and you know physical therapy students get a little touch of balance and so they know how to treat the BPPV balance issues. It's really their experience. So in a rural area, I would still say, start with physical therapy and they can help get you on the road to recovery. If you are in a more urban area, it's great if you have somebody that's specific to balance. I mean it is just physical therapy for that whole vestibular system that goes from your inner ears and your vision and your proprioception to your brain and making them all talk to one another. So there's very specific exercises that you can do, things that they'll have you do at home to help that system recover more quickly.

Speaker 2: 11:41

I always tell my patients as well that I know you may not feel like you've got whether it's great balance, but don't not do anything or it's not going to get better. It's kind of like your whole system needs to recalibrate again and if you're not using it it's not going to ever be able to do those things that you could do again. So I always tell people to kind of push their limits a little bit. But definitely physical therapist is a way to go and most physical therapists now are direct access and so they don't necessarily have to go through a physician.

Speaker 2: 12:12

That may vary depending on where you are, but if somebody is struggling or you know they don't have access to an otolaryngologist, it might be helpful to just go directly to physical therapy. And if that physical therapist I know ours are say you are just too significant right now. Anything we try to do with you, you're going to vomit, they at least then know a physician that say, hey, can you help here? This person really needs to be treated. And then we'll see him back in a week or two and really start working on therapy with them. That's how it's worked in ours. It's great because now a lot of patients in our area will go directly to our therapist and we'll get a phone call and say, hey, can we send this person down Because they're not ready for treatment yet. They need some medical therapy first.

Speaker 1: 12:55

Yeah, yeah, okay. So if you see that and somebody is throwing up all the things like, er is probably the first place to go.

Speaker 2: 13:04

It probably is. If they really are not getting in I mean they're not able to eat, they're not able to drink, they're not able to function they do need an ER visit just to rule out the bigger things. Like I said, you know stroke, you know other things that can cause real central vertigo. A post concussive disorder can do it, multiple sclerosis can do it, any kind of increased pressure. But they're at least going to get some IV treatment to settle it. Initially. Hopefully they do get them on a steroid and some kind of central vestibular suppressant to keep them functioning, and then I would really try to get them into a physical therapist or an otolaryngologist fairly quickly if they can, yeah, okay.

Speaker 1: 13:46

So I think that was the piece that was missing for us. Like you know, didn't know where to go next, so I think that's important.

Speaker 2: 13:52

So, what's the third? Okay, so the third goes back to that middle one. If somebody says you know it happens for hours but it's it's longer than minutes and it's not necessarily days, and that you know most of the time in history, people have kind of said that's a Meniere's territory, and let me describe so. Meniere's disease is something that classically we see in ENT is a combination of ear pressure increasing tinnitus or ringing in your ears, a fluctuating hearing loss and vertigo, and it's thought to be due to an increase in pressure within the inner ear that then causes a rupture of one of the membranes within the labyrinth or the inner ear. But there's a lot of overlap and a lot of research now really looks at these kind of middle timeframe or hours kind of tips of vertigo or of being more migraine related, and so most of the time now we're treating these as a vestibular migraine and there's a huge overlap between migraine and Meniere's. And so that's really where this is the majority of patients that I see that it's not that easy chip shot positional vertigo.

Speaker 2: 15:03

It's the ones that have episodes that they may be out of work for a day to maybe even up to a week. Um, they're more comfortable lying in bed. They might not be throwing up all day, but they describe it for me as usually vertigo and then feeling like they're hung over for several days, like they're just ill. They're not necessarily um spinning that whole time, but just feel like they can't function great, and so this is where it really is more. There's a lot of different things that we can do. I mean, certainly, when I try to describe this as migraine, the first thing people say is I don't have a headache, like I know. But the whole process of what happens in the brain and with your neurons can give you more of vertigo and spinning rather than a headache. It just depends on what neurons are involved, and so I have a nice handout that I borrowed from a great neurotologist, which is the subspecialist of ENT that just does inner ear and ear things out in California.

Speaker 2: 16:04

I think I've shared that with you but, yeah of kind of a treatment algorithm and he has kind of an outline as to true medications that we'll use that are more of migraine prophylaxis. But in the short term, these are the ones where things like meclizine and then acute migraine treatments can be really helpful. And so these are the ones that I say meclizine and then acute migraine treatments can be really helpful. And so these are the ones that I say meclizine is great, but you shouldn't be on it every day, like you shouldn't be taking it twice a day, three times a day. It's really meant for a treatment when you're symptomatic and if somebody can get on it right away when they start having symptoms and then even take some kind of a you know, over the counter headache medication. I know you might not have a headache, but I always tell people if you can take an Excedrin and a Meclizine and lay down for a couple hours, and it's amazing how many of them come back and say, wow, that worked. Now we need to see is this happening a lot? Do you need to be on something more? But we really then go back to also what are the triggers for migraine, and they can be things like diet, it can be stress, it can be sleep, it can be allergies, and so you combine a couple of those like this time of year of allergies really being triggered, and maybe somebody like in my own world getting ready for a high school graduation, so you're maybe not eating the best or not staying hydrated and you have multiple triggers that all build up. You're going to have symptoms and so really trying to identify those can be very, very helpful.

Speaker 2: 17:36

Another big one that this is a great little tip for pharmacists too. If people do get these quite frequently, whether it's for vertigo and vestibular migraine or even just migraine in general a prophylactic like supplement. I put all of my patients on a magnesium supplement that they'll take 400 milligrams twice a day. They might need to start a little low dose to not get diarrhea as a side effect and also riboflavin or vitamin B2, like 200 milligrams twice a day. Those are a little bit higher doses than what a lot of the over-the-counter preparations come in. But those as the daily prophylactic can be just true game changers in preventing these episodes and I think once patients start to realize that this isn't just something they have to live with and they can really control a lot of those triggers and the things that they can do right when they have symptoms to help prevent it from being a multi-day feeling really crummy. It can really turn their world around and make them feel a lot better.

Speaker 1: 18:41

So how does what's the difference between that and Meniere's Like how, how do you, how do you diagnose, like if it's something more chronic that that's not going to work for, or does some of that preventative stuff work for Meniere's as well?

Speaker 2: 18:56

The biggest thing that the research has come out recently is that a lot of that preventative stuff and the migraine treatment works for Meniere's and so right now.

Speaker 2: 19:04

I usually treat them about the same um, you know, truly diagnosing many years like the. There's not a test that we can just do for it. The baseline that we go off of is, if I can document somebody with a fluctuating what we call sensory neurohearing loss, so their hearing goes down. It might be down for a couple of days to a week and I can repeat it again and it's completely back to normal. There are very, very few things that do that, except for Meniere's. So once I get to that point and they have that classic symptoms, we can treat them as Meniere's.

Speaker 2: 19:39

The classic treatments for Meniere's typically have been a low salt diet, because high salt content can be a trigger for them, and usually then the medications in the diuretic families. So you'll see people on like hydrochlorothiazide and tramperine and things like that that can be specifically for Meniere's, and then they're just on it for a while. And then there are other things that we can do there Intratempanic injections that we can do acutely for Meniere's episodes there's. Even you can go to the point of doing surgery on the inner ear to not have that response anymore, but those are really rare.

Speaker 2: 20:18

One thing I was going to say too is with a lot of these patients, like even once we talk about this migraine kind of diagnosis is, some of these patients may be on prophylactic medications, but they're not a lifetime thing and so once they've gone a while without you know, it might just be maybe a year, and usually once they've been several months symptom free, I really talk about weaning them off. So that's another aspect, that when you see people come in on multiple meds and start digging into that, if they were diagnosed and put on something five years ago for this and they're now symptom free, that's really one that you can talk about tapering off with their physician and I think that's reassuring for people to to not know that this is going to be something that they'll suffer with for a long time.

Speaker 1: 21:04

Yeah, yeah, well, I had. You know, I started this by saying we've had some incidents and I actually had this. So I had it was diagnosed as migraines, but it was 15 years ago and it was awful, I mean, I will say from a personal standpoint. I mean, of course, my first thing I went to a brain tumor or you know, I mean it's because your world is really spinning. I mean just vomiting and I ended up in an ambulance and I think, you know, when I look back, I think it was stress. You know, I've gotten regular massages to. You know, I sit at my desk so much and so I think, like all those nerve bundles sort of in the back of my neck, but I had that same thing. So you know it would last.

Speaker 1: 21:41

I mean my sort of hangover would be almost a week where I just was a pile, I mean I just couldn't do much of anything.

Speaker 1: 21:53

And finally, when I got that diagnosis, I felt so free because I thought I had Meniere's and then I was afraid to go to the grocery store. I mean I was like I just don't know when this is going to happen again, because I really didn't have an aura, like I felt like that was my aura, I would just immediately get dizzy, and I was. You know I had. I would carry around in the trucks, you know, in my purse all the time, just in case, and I used it for, I would say, probably a year to a year and a half and then after that I, you know, knock on wood haven't had any issues. So I think your point is well taken that you know you're nervous to get off of that prophylactic treatment because you don't want it to happen again. But you know, if you can kind of get a handle on all the other things that maybe we're causing it, then it's not something we need to be on long-term. So yeah, that's a great point.

Speaker 2: 22:36

Yeah, and one other thing I like to throw in there is people that are very apt to be motion sick. There is a huge, huge connection between motion sickness and migraine. So that's another kind of clue is if even they come in with vertigo and they're like, oh, this usually happens if I'm in the backseat of a car, I'm on a boat, that's a huge clue to me that it's probably migraine because of that overlap of the pathophysiology of both of those. So anything, even as just an acute, make them feel better as a motion sickness type of medication or over-the-counter treatment, and then really think of what would you recommend for somebody that came in with a horrible headache. So I said, one of my favorite things is you know, an Excedrin and a Meclizine are two over-the-counter treatments. If there's no contraindications to those, that can make a big difference for a lot of people with these symptoms before they can get in to see somebody else.

Speaker 1: 23:30

Yeah, yeah, yeah, that's super helpful, I think. I just think that's something that people don't. You know, you know of Meniere's, you know, you know of the, you know the benign proxies, and now, I can't even say it, ppv.

Speaker 2: 23:43

Yes, I know it is a mouthful. Yes, yeah, you know, the benign prox is and now I can't even say it PPV, yes, I know it is a mouthful.

Speaker 1: 23:48

Yes, yeah, you know, you hear of those two things, but I think you don't often hear of, you know, the vestibular migraine, and I think that's that's great advice for people that can't, you know, they can't figure out what else it is. So so let's recap really quickly, cause I think that's, you know, that was my big thing. Big takeaway here is I just feel like there's this gap in really knowing what it is kind of put everybody into one bucket, which isn't true. So so if you're, if you're seeing patients like what are the, what are the questions to ask and then where to triage, just as a quick, recap.

Speaker 2: 24:20

Yeah, I would say the first question to ask is is it really vertigo? Is it spinning? Is their world moving in some sort? And if so, how long does it last?

Speaker 2: 24:29

If it's seconds to minutes, they really need to see just a physical therapist, and any physical therapist can usually treat this and get some decent results.

Speaker 2: 24:38

If it is hours to kind of that, maybe a day at the most, that's where we think of that Meniere's and migraine and treating, and that's where meclizine is probably the most helpful, or those motion sickness type of medications, along with thinking along the headache standpoint, and then maybe those you know prophylactic supplements and things, and and eventually seeing somebody that is willing to treat this.

Speaker 2: 25:04

Unfortunately, a lot of neurologists don't necessarily want to manage a bunch of vestibular migraine but their primary care and otolaryngologist that's willing to see them. And then the last one is the ones that are days I mean truly days of vomiting and not able to function is more of that neuritis category, and although meclizine and the over-the-counters may take a little edge off, they need something stronger, like prednisone and a central vestibular suppressant like lorazepam, and those are the ones that probably are being seen in the emergency room and they'll get an IV cocktail of things to settle it down and then hopefully they're getting something to go out the door with to keep them okay, or they're just going to end up right back there within about 48 hours and those are the ones that are really, really helpful to get into a vestibular physical therapist to get back to being a hundred percent, and it's going to take a month to get there.

Speaker 1: 26:00

Yeah, I would say a month to a month and a half. I mean, that's, you know, six, six weeks was probably a good marker for, for my husband anyway, what I saw it play out. Yeah, yeah, yes.

Speaker 2: 26:12

And unfortunately, if that happens in an older population, they may actually be in the hospital for several days before they can even keep food down. It's just the older we get, the slower we are to heal. But usually people do get back to a good baseline where they are functional. It might catch them off guard every once in a while here and there, but they usually get back pretty well.

Speaker 1: 26:32

Well, particularly an elderly with that balance too, really important because you don't want to fall or something. So, yeah, that would be a different category. Well, this was great. Thank you so much for being with me today. It was super fun to do it with you and it's something we've been talking about for a long time, so I hope people found it valuable. I think it's really good information for all of us to have. Again, if 40% of people are experiencing some type of dizziness or vertigo, I think that was a really good point out too. Not a diagnosis, but a symptom, you know, then it's it's great to have resources to be able to point them in the right way. You mentioned some really good prophylactic things, so, again, we'll make sure that we put those in the show notes. That was something that I was frantically taking notes while we were talking, so I think that would be helpful for people to recommend as well. So, thank you so much. This was really fun.

Speaker 2: 27:27

It was fun and hopefully. I know we've talked about some other ones, so maybe we'll come up with more topics now that I've got my first one out of the way. Yeah.

Speaker 1: 27:34

See, it's not so bad, I just started a couple months ago and now I'm, you know, old pro. Um, it's just like having a conversation, so it's super fun, and I think it's also great to listen to too, because you just feel like you're kind of a fly on the wall listening to somebody's conversation. So I'm loving podcasts. Thanks again so much. It was really fun today to do this with you, and that is it for this week. So if you're a CE plan member, be sure to claim your CE credit for this episode by logging in at ceimpactcom and, as always, have a great week and keep learning. We'll talk to you next week, you.