The simple mnemonic “SO STONED” can help diagnose vertigo. What “fingerprint” do positional vertigo, vestibular migraine, neuritis and co. leave in this standardized anamnesis tool?
“SO STONED” [1] is a simple mnemonic applicable in family practice as well as in the emergency department to approach diagnosis finding in eight dimensions of vertigo (after stroke has been ruled out as a cause [2]). These are:
- Symptoms
- How often?
- Sincewhen?
- Symptom Trigger
- Otology
- Neurology
- Symptom evolution
- Duration.
The history is essential in a patient with vertigo to elicit the potential etiology. However, it is also prone to error because the vocabulary used to describe the disturbances in the sense of balance and orientation can be very imprecise and varies greatly from individual to individual.
“So initially, the main thing is to collect the timing, symptom and trigger profile of the disease as completely, standardized and quickly as possible,” said Prof. Floris Wuyts, MD, Antwerp. “Determination and control of our spatial body orientation are extremely complex: information originating from graviceptor systems of the internal organs, proprioceptive input, the actual balance organ of the inner ear as well as visual perception are processed in the brain and influence our gaze stabilization, orientation and navigation in space, our balance and autonomic function as well as the circadian rhythm. Since most forms of vertigo – at least in their typical manifestation – leave a clear fingerprint in the dimensions of SO STONED, an initial differential diagnosis thus becomes much easier. Of course, this is followed by further investigations, whether clinical, laboratory or possibly imaging.”
Table 1 sheds some light on the various dimensions of “SO STONED.”
Case 1: Almost daily dizziness for a few weeks
In several case presentations, Prof. Wuyts discussed the various differential diagnoses of vertigo, always on the basis of the mnemonic “SO STONED”. In the first case, the “fingerprint” was as follows: S (spinning vertigo), O (almost every day), S (for a few weeks), T (turning over in bed, bending over, general head movements, standing up, reaching for something above the head), O (nothing specific), N (nothing specific), E (gradually better, but still not good), D (seconds).
Solution: Benign peripheral paroxysmal positional vertigo or BPPV, which by the way can be well explained to the patient with a “snow globe” – e.g. such with a miniature house in it etc. – can be treated with various physiotherapeutic maneuvers (preferably targeted reduction maneuvers instead of Brandt-Daroff). For the posterior archway, the Epley and Semont maneuvers exist: both have good healing rates, but the former is more commonly used in German and English-speaking countries and can also be more easily repeated by the patient if the treatment at the doctor’s office did not help immediately or in the case of a recurrence. For some sufferers with severe nausea, (pre)medication accompaniment with e.g. dimenhydrinate is necessary in order to be able to perform the release maneuvers correctly (and without fear) in the first place. In the case of history of relatively typical BPPV but absent or atypical nystagmus, possible differential diagnoses should be considered.
Case 2: Repeated reversible attacks, sometimes lasting for days, with headache
The second case is also relatively typical with the following “fingerprint”: S (vertigo attacks), O (variable, in certain periods daily, then only a few times a month or monthly), S (several months), T (movement, but also spontaneous), O (nothing), N (headache/migraine now and then, motion sickness), E (an up-and-down), D (seconds, minutes, hours, days).
Solution: For definite and probable vestibular migraine, the diagnostic criteria of Lempert et al. exist since 2012. [3]. Nevertheless, the clinical picture continues to be overlooked by many primary care physicians, which may not do justice to the real frequency in the population. There is an association and difficulty in clinical differentiation from Meniere’s disease (especially in the absence of hearing loss). Definite vestibular migraine is defined by
A: at least five episodes of vestibular symptoms of moderate to severe severity over five minutes each (sum of multiple seizures) up to 72 hours
B: Current or past history of migraine with/without aura according to ICHD.
C: During at least half of all vertigo attacks, migraine symptoms (unilateral/pulsating/moderate to severe pain/exacerbation by routine activities as well as phonophobia, photophobia, visual aura).
D: Not explainable by other disease.
In the “probable” form, only one of the B-/C-criteria is fulfilled. In addition to sleep, diet and daily hygiene (as in classic migraine) and coffee avoidance, flunarizine or (also after appropriate comorbidities) e.g. propranolol/metoprolol, topiramate are used for treatment. In addition, for prolonged episodes of vertigo lasting more than 30 minutes, nonspecific treatment with an antivertiginosum can be given during the episode.
Case 3: Persistent severe spinning dizziness after a cold
The following “SO STONED” case immediately raises a suspicious diagnosis: S (acute onset with severe spinning dizziness with nausea and vomiting, sideways staggering, oscillopsia), O (single, not recurrent), S (since a few days, previously patient had a flu-like infection/cold), T (with every head movement, but symptoms also present when patient lies still in bed), O (nothing, i.e. no hearing loss, tinnitus or pressure sensation), N (nothing, i.e. no headache/tears, no paresthesia), E (gradually improving, i.e. no hearing loss, tinnitus or pressure sensation).e. no hearing loss, tinnitus or pressure sensation), N (nothing, i.e. no headache/migraine, no paresthesia), E (gradually getting better), D (days).
Solution: Neuritis is approximately the fourth most common vestibular disorder. A viral infection/inflammatory lesion of the (usually superior segment of the) vestibular nerve, e.g., due to reactivation of HSV-1, is a possible cause. Peripheral-vestibular function recovers in 40-63% of cases, depending on corticosteroid treatment, and the recurrence rate is approximately 2% in ten years [4]. In addition to temporary treatment with glucocorticoids, short-term symptomatic therapy with antiemetics/antivertiginosa may be useful in the first few days of neuritis vestibularis with pronounced nausea and vomiting. In addition, early gradual mobilization and vestibular physiotherapy exercises resp. Balance training.
Case 4: Frequent attacks of vertigo lasting seconds to minutes.
A 33-year-old woman has the following dizziness profile: S (dizziness, lightheadedness), O (daily), S (for one year), T (changing position, turning head while driving), O (unilateral hearing loss, bilateral tinnitus), N (headache, cervical pain), E (worsening), D (regular, seconds to minutes). Clinical examination reveals positional horizontal nystagmus.
Solution: The diagnosis is a vestibular paroxysm, i.e., a vessel-nerve contact or neurovascular conflict with ephaptic transmission of excitation visible on MRI. Overview 1 shows the disease criteria valid since 2016 [5]. Some patients report auditory symptoms during attacks, which may include tinnitus or hypacusis. Especially when examined during a seizure, horizontal and torsional nystagmus is seen to deflect to the affected ear. By the way, the mentioned MRI finding is also encountered in about 30% of healthy people without corresponding symptoms. The treatment of choice is carbamazepine (Tegretol®) administered slowly over at least four weeks. Differential diagnoses may include: BPPV, Meniere’s disease and vestibular migraine. Typical of vestibular paroxysmia are the daily BPPV-like symptoms (change of position of the head or body) with, however, a non-BPPV-typical nystagmus in Dix-Hallpike position. The very short attacks occur several times a day, the symptoms often exist for months or years, MRI shows neurovascular findings. Patients respond to carbamazepine, vestibular rehabilitation tends to worsen symptoms.
Source: SGORL Spring Meeting, June 21-22, 2018, Basel.
Literature:
- Wuyts FL, Van Rompaey V, Maes LK: “SO STONED”: Common Sense Approach of the Dizzy Patient. Front Surg 2016 Jun 1; 3: 32.
- Kattah JC, et al: HINTS to diagnose stroke in the acute vestibular syndrome: three-step bedside oculomotor examination more sensitive than early MRI diffusion-weighted imaging. Stroke 2009 Nov; 40(11): 3504-3510.
- Lempert T, et al: Vestibular migraine: diagnostic criteria. J Vestib Res 2012; 22(4): 167-172.
- Brandt T, et al: Long-term course and relapses of vestibular and balance disorders. Restor Neurol Neurosci 2010; 28(1): 69-82.
- Strupp M, et al: Vestibular paroxysmia: Diagnostic criteria. J Vestib Res 2016; 26(5-6): 409-415.
HAUSARZT PRAXIS 2018; 13(8) – published 7.7.18 (ahead of print).
