From the Guidelines
The workup of dizziness should begin with a detailed history to distinguish between vertigo, lightheadedness, disequilibrium, or presyncope, as this guides further evaluation. Physical examination should include vital signs, orthostatic measurements, neurological assessment, and specialized tests like the Dix-Hallpike maneuver for benign paroxysmal positional vertigo (BPPV) 1. Laboratory tests typically include complete blood count, metabolic panel, thyroid function, and glucose levels to identify anemia, electrolyte disturbances, or metabolic causes. Depending on clinical suspicion, additional testing may include electrocardiogram to assess for arrhythmias, brain imaging (CT or MRI) if neurological causes are suspected, and audiometry for inner ear disorders. Specialized tests like electronystagmography or vestibular evoked myogenic potentials may be needed for persistent symptoms. The workup should be tailored to the patient's presentation, with peripheral vestibular disorders like BPPV and vestibular neuritis being common causes of true vertigo, while orthostatic hypotension, medication side effects, and cardiovascular issues often cause lightheadedness. Prompt evaluation of sudden, severe dizziness with neurological symptoms is essential to rule out serious conditions like stroke or transient ischemic attack 1.
Some key points to consider in the workup of dizziness include:
- Distinguishing between vertigo, lightheadedness, disequilibrium, and presyncope to guide further evaluation
- Performing a thorough physical examination, including vital signs, orthostatic measurements, and neurological assessment
- Using specialized tests like the Dix-Hallpike maneuver for BPPV
- Ordering laboratory tests to identify underlying causes, such as anemia, electrolyte disturbances, or metabolic disorders
- Considering additional testing, such as electrocardiogram, brain imaging, or audiometry, based on clinical suspicion
- Tailoring the workup to the patient's presentation and suspected underlying cause
It's also important to note that the diagnostic yield of CT and MRI imaging is low in patients with isolated dizziness, and that the HINTS examination can be useful in distinguishing between peripheral and central causes of vertigo 1. Additionally, patient education and counseling are important aspects of managing BPPV, including discussing the risk of falls and the importance of follow-up care 1.
From the Research
Work-up of Dizziness
The work-up of dizziness involves a systematic patient history and physical exam to accurately diagnose conditions related to dizziness 2. The evaluation focuses on determining whether the etiology is peripheral or central, with peripheral etiologies being usually benign and central etiologies often requiring urgent treatment 3.
Key Components of the Work-up
- A timing-and-triggers approach to characterize the patient's vestibular symptoms as continuous or episodic 4
- Determining whether symptoms are post-exposure or spontaneous 4
- Classifying the patient as having post-exposure acute vestibular syndrome (AVS), spontaneous AVS, triggered episodic vestibular syndrome (EVS), or spontaneous EVS 4
- Physical examination including:
- Orthostatic blood pressure measurement
- Full cardiac and neurologic examination
- Assessment for nystagmus
- The Dix-Hallpike maneuver 3
- The HINTS (head-impulse, nystagmus, test of skew) examination to help distinguish peripheral from central etiologies 3
Treatment Options
- Benign paroxysmal positional vertigo can be treated with a canalith repositioning procedure (e.g., Epley maneuver) 3
- Meniere disease can be treated with salt restriction and diuretics 3
- Vestibular neuritis can be treated with vestibular suppressant medications and vestibular rehabilitation 3
- Acute peripheral vertigo can be treated with oral medications such as diazepam and meclizine, which have been shown to be equally effective 5
- Medical therapies for dizziness can include antihistamines, calcium channel blockers, and benzodiazepines for acute peripheral vertigo, and prophylactic pharmacotherapies such as betahistine and diuretics for Meniere disease 6