From the Guidelines
The workup for dizziness should begin with a detailed history to distinguish between vertigo, lightheadedness, disequilibrium, or presyncope, as these suggest different etiologies. Physical examination should include vital signs, orthostatic measurements, cardiovascular assessment, neurological examination including cranial nerves, cerebellar testing, and the Dix-Hallpike maneuver to evaluate for benign paroxysmal positional vertigo (BPPV) 1. Laboratory tests should include complete blood count, basic metabolic panel, thyroid function tests, and blood glucose to rule out anemia, electrolyte abnormalities, thyroid dysfunction, and hypoglycemia. For persistent or concerning symptoms, additional testing may include electrocardiogram to assess for arrhythmias, brain imaging (CT or MRI) if neurological causes are suspected, audiometry for hearing-related vertigo, and vestibular function tests like electronystagmography. Specialized tests such as carotid ultrasound or echocardiogram may be warranted if vascular or cardiac causes are suspected.
Key Considerations
- The history and physical examination should evaluate for neurologic, other neurotologic/otologic, oncologic, inflammatory, or infectious or vascular causes 1.
- The Dix-Hallpike maneuver is considered the gold standard test for the diagnosis of posterior canal BPPV 1.
- Clinicians should not obtain radiographic imaging in a patient who meets diagnostic criteria for BPPV in the absence of additional signs and/or symptoms inconsistent with BPPV that warrant imaging 1.
- The use of CT imaging in patients with acute vertigo and a normal neurologic examination has a low detection rate of contributory central nervous system pathology [<1%] 1.
Diagnostic Approach
- Start with a detailed history and physical examination to distinguish between different types of dizziness.
- Use the Dix-Hallpike maneuver to evaluate for BPPV.
- Consider laboratory tests and additional imaging or specialized tests as needed based on the patient's symptoms and examination findings.
- Be cautious of the low yield of CT imaging in patients with acute vertigo and a normal neurologic examination, and consider alternative diagnostic approaches such as the HINTS examination 1.
From the Research
Diagnostic Approach
The diagnostic approach for dizziness involves a thorough history and physical examination, with additional tests rarely necessary 2. The history should focus on the timing and triggers of dizziness, as patients often have difficulty describing the quality of their symptoms 3, 4. The physical examination may include:
- Orthostatic blood pressure measurement
- A full cardiac and neurologic examination
- Assessment for nystagmus
- The Dix-Hallpike maneuver (for patients with triggered dizziness)
- The HINTS (head-impulse, nystagmus, test of skew) examination when indicated 3, 4
Differential Diagnosis
The differential diagnosis for dizziness is broad and includes peripheral and central causes 3, 4. Peripheral etiologies can cause significant morbidity but are generally less concerning, whereas central etiologies are more urgent. The diagnosis can be divided into three key categories using timing and triggers:
- Acute vestibular syndrome
- Spontaneous episodic vestibular syndrome
- Triggered episodic vestibular syndrome 5
Treatment
The treatment for dizziness is dependent on the etiology of the symptoms 4. Some common treatments include:
- Canalith repositioning procedures (e.g., Epley maneuver) for benign paroxysmal positional vertigo
- Vestibular rehabilitation for many peripheral and central etiologies
- Pharmacologic intervention, although limited, to address the cause of dizziness 3, 4
- Salt restriction and diuretics for Meniere disease 3
- Vestibular suppressant medications and vestibular rehabilitation for vestibular neuritis 3