From the Guidelines
The workup for dizziness should begin with a detailed history to distinguish between vertigo, lightheadedness, disequilibrium, or presyncope, as this guides further evaluation. This approach is crucial in identifying the underlying cause of dizziness, which can significantly impact morbidity, mortality, and quality of life. According to the clinical practice guideline on Ménière's disease 1, a thorough history and physical examination should evaluate for neurologic, other neurotologic/otologic, oncologic, inflammatory, or infectious or vascular causes.
The history should include questions about the nature of the onset, duration of active vertigo, and concurrent otologic symptoms, as well as inquiries about head position, falls, and loss of consciousness. A thorough otologic history, including prior ear surgery, otorrhea/chronic ear infections, otalgia, or prior hearing loss, should also be addressed.
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. Initial laboratory testing should include complete blood count, basic metabolic panel, thyroid function tests, and glucose measurement to identify anemia, electrolyte abnormalities, or metabolic causes.
Electrocardiogram is recommended to evaluate for cardiac arrhythmias, especially in older patients or those with cardiac risk factors. Imaging studies like MRI of the brain may be indicated if central causes are suspected, particularly with neurological symptoms or risk factors for stroke. Audiometry and vestibular testing can help diagnose peripheral vestibular disorders.
Some key points to consider in the workup of dizziness include:
- Distinguishing between vertigo, lightheadedness, disequilibrium, and presyncope
- Evaluating for neurologic, otologic, and vascular causes
- Using specialized tests like the Dix-Hallpike maneuver for BPPV
- Considering laboratory testing, including complete blood count, basic metabolic panel, and electrocardiogram
- Referring to specialists like neurology, otolaryngology, or cardiology for persistent or unexplained dizziness
By following this approach, clinicians can provide timely and effective management of dizziness, reducing the risk of morbidity, mortality, and improving quality of life. As noted in the clinical practice guideline on BPPV 1, the diagnosis of BPPV is based on the clinical history and physical examination with a positive result on the Dix-Hallpike test, and comprehensive vestibular testing is unnecessary for patients who already meet clinical criteria for the diagnosis of BPPV.
From the Research
Dizziness Workup
- Dizziness is a common but often diagnostically difficult condition, and clinicians should focus on the timing of events and triggers of dizziness to develop a differential diagnosis 2, 3, 4.
- The differential diagnosis is broad and includes peripheral and central causes, with peripheral etiologies generally being less concerning and central etiologies being more urgent 2, 3.
- The physical examination for dizziness may include:
- Laboratory testing and imaging are usually not required but can be helpful in certain cases 2, 3, 5.
Treatment of Dizziness
- The treatment for dizziness is dependent on the etiology of the symptoms 2, 3.
- Canalith repositioning procedures (e.g., Epley maneuver) are the most helpful in treating benign paroxysmal positional vertigo 2, 3.
- Vestibular rehabilitation is helpful in treating many peripheral and central etiologies 2.
- Other etiologies of dizziness require specific treatment to address the cause, such as salt restriction and diuretics for Meniere disease, and vestibular suppressant medications and vestibular rehabilitation for vestibular neuritis 3.