What is the diagnostic workup for vertigo (dizziness)?

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, and physical examination should include vital signs, orthostatic measurements, neurological assessment, and tests like the Dix-Hallpike maneuver for benign paroxysmal positional vertigo (BPPV) 1.

Key Components of the Workup

• A thorough history to identify the type of dizziness and its duration, onset, and associated symptoms
• Physical examination including:
  • Vital signs
  • Orthostatic measurements
  • Neurological assessment
  • Dix-Hallpike maneuver for BPPV
• Laboratory tests:
  • Complete blood count
  • Basic metabolic panel
  • Thyroid function tests
  • Glucose measurement

Additional Testing Based on Clinical Presentation

• Electrocardiogram to assess for arrhythmias
• Brain imaging (CT or MRI) if neurological symptoms are present
• Audiometry for hearing-related dizziness
• Vestibular function tests like electronystagmography

Considerations for Specific Conditions

• For suspected BPPV, the Epley maneuver can be both diagnostic and therapeutic 1
• Patients with recurrent unexplained dizziness may benefit from 24-hour Holter monitoring or tilt-table testing to evaluate for cardiac causes
• The workup should be tailored to the patient's age, risk factors, and associated symptoms, as dizziness in younger patients often has different etiologies compared to older adults 1

Recent Guidelines and Recommendations

• The American Academy of Otolaryngology-Head and Neck Surgery Foundation recommends a thorough history and physical examination, and selective use of diagnostic tests based on the clinical presentation 1
• The American College of Radiology recommends imaging for patients with acute persistent vertigo and a normal neurologic examination only if the HINTS examination is not available or is positive for central causes 1

From the Research

Workup for Dizziness

The workup for dizziness involves a thorough history and physical examination to determine the underlying cause of the symptoms.

• The history should focus on the timing and triggers of the dizziness, as patients may have difficulty describing the quality of their symptoms 2, 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 2, 4.
• Laboratory testing and imaging are usually not required but can be helpful in certain cases 2, 5, 4.

Differential Diagnosis

The differential diagnosis for dizziness is broad and includes peripheral and central causes.

• Peripheral etiologies can cause significant morbidity but are generally less concerning, whereas central etiologies are more urgent 2.
• The timing and triggers diagnostic approach can help differentiate between benign peripheral vestibular conditions and dangerous posterior circulation strokes 3.
• Patients can be divided into three key categories:
  • Acute vestibular syndrome
  • Spontaneous episodic vestibular syndrome
  • Triggered episodic vestibular syndrome 3.

Treatment

The treatment for dizziness is dependent on the etiology of the symptoms.

• Canalith repositioning procedures (e.g., Epley maneuver) are the most helpful in treating benign paroxysmal positional vertigo 2, 4.
• Vestibular rehabilitation is helpful in treating many peripheral and central etiologies 2, 4.
• 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 4.