What is the appropriate workup for a patient presenting with dizziness?

From the Guidelines

A comprehensive dizziness workup should begin with a detailed history and physical examination, including specialized tests like the Dix-Hallpike maneuver and head impulse test, to distinguish between vertigo, lightheadedness, disequilibrium, or presyncope, as this guides further evaluation. The physical examination should include vital signs, orthostatic measurements, neurological assessment, and specialized tests like the Dix-Hallpike maneuver for benign paroxysmal positional vertigo (BPPV) and the head impulse test for vestibular dysfunction 1.

Some key points to consider in the workup include:

• Laboratory testing should include complete blood count, comprehensive metabolic panel, thyroid function tests, and vitamin B12 levels to rule out metabolic causes.
• Depending on the clinical presentation, additional tests may include electrocardiogram, Holter monitoring, or tilt-table testing for cardiac causes; audiometry for hearing-related vertigo; and imaging studies such as CT or MRI of the brain to evaluate for central causes like stroke or multiple sclerosis.
• For peripheral vestibular disorders, vestibular function tests like electronystagmography or videonystagmography may be appropriate.
• The HINTS examination can be used to distinguish between central and peripheral causes of vertigo, and can help guide the need for imaging studies 1.
• Treatment depends on the underlying cause: BPPV responds to canalith repositioning maneuvers like the Epley procedure; vestibular neuritis may require short-term vestibular suppressants like meclizine 25mg every 4-6 hours for 1-3 days along with vestibular rehabilitation; and Ménière's disease often requires salt restriction, diuretics like hydrochlorothiazide 25mg daily, and sometimes betahistine 16mg three times daily.

It is also important to note that imaging studies such as CT or MRI of the brain should not be routinely ordered in patients with dizziness, but rather should be guided by the clinical presentation and results of the physical examination and laboratory tests 1. Persistent or recurrent dizziness warrants referral to specialists such as neurologists, otolaryngologists, or cardiologists based on suspected etiology.

In terms of specific guidelines, the American College of Radiology recommends that imaging studies be ordered based on the clinical presentation and results of the physical examination and laboratory tests, rather than as a routine part of the dizziness workup 1. This approach can help to reduce unnecessary testing and improve patient outcomes.

From the Research

Dizziness Workup

• The approach to evaluating dizziness involves determining whether the etiology is peripheral or central, with peripheral etiologies being usually benign and central etiologies often requiring urgent treatment 2, 3.
• The physical examination includes orthostatic blood pressure measurement, a full cardiac and neurologic examination, assessment for nystagmus, and the Dix-Hallpike maneuver 2, 3, 4.
• The HINTS (head-impulse, nystagmus, test of skew) examination can help distinguish peripheral from central etiologies 2, 3.
• Laboratory testing and imaging are usually not required, but can be helpful in certain cases 2, 3, 5.

Diagnostic Approach

• A thorough history and physical examination are the most useful diagnostic approaches in distinguishing different types of dizziness 5.
• The timing and triggers of dizziness can help guide a differential diagnosis and targeted bedside examination protocol 6.
• Patients can be divided into three key categories: acute vestibular syndrome, spontaneous episodic vestibular syndrome, and triggered episodic vestibular syndrome 6.

Treatment

• The treatment for dizziness is dependent on the etiology of the symptoms 3.
• Canalith repositioning procedures (e.g., Epley maneuver) are effective in treating benign paroxysmal positional vertigo 2, 3, 4.
• Vestibular rehabilitation is helpful in treating many peripheral and central etiologies 3.
• Pharmacologic intervention is limited, as it often affects the ability of the central nervous system to compensate for dizziness 3.