What are the pertinent questions to ask during a dizziness (vertigo) evaluation?

From the Guidelines

When evaluating dizziness, it is crucial to ask about the specific sensation experienced, onset and duration of symptoms, and any triggers or alleviating factors, as this information can help differentiate between peripheral and central causes of dizziness, guiding appropriate diagnostic testing and management. The following questions should be asked:

• The specific sensation experienced (vertigo, lightheadedness, unsteadiness, or disequilibrium)
• Onset and duration of symptoms
• Any triggers or alleviating factors
• Associated symptoms such as nausea, vomiting, hearing changes, tinnitus, headache, or neurological symptoms like weakness, numbness, or visual disturbances
• If symptoms are constant or episodic, and if episodic, ask about frequency and duration of episodes
• A complete medication history, including recent changes, as many medications can cause dizziness as a side effect
• Recent illnesses, especially respiratory or ear infections, and any history of head trauma
• Cardiovascular risk factors and symptoms like chest pain or palpitations
• Positional changes triggering symptoms, which might suggest orthostatic hypotension or benign paroxysmal positional vertigo
• Past medical history, particularly ear problems, migraines, stroke, or cardiovascular disease
• How symptoms impact daily activities and quality of life, as this information can help guide management and treatment decisions 1. It is also essential to consider the clinical presentation and differentiating features of various conditions that can cause vertigo or dizziness, such as Meniere's disease, benign paroxysmal positional vertigo, vestibular migraine, and stroke, to ensure accurate diagnosis and treatment 1. Additionally, the use of bedside tests like the HINTS examination can help distinguish between benign peripheral causes and posterior circulation infarct, and imaging may be required to rule out stroke in certain cases 1.

From the FDA Drug Label

1. 1 Drowsiness Since drowsiness may occur with use of meclizine hydrochloride tablets, patients should be warned of this possibility and cautioned against driving a car or operating dangerous machinery. 6 ADVERSE REACTIONS ... drowsiness, ...

The FDA drug label does not answer the question.

From the Research

Evaluation of Dizziness

To evaluate dizziness, clinicians should focus on the following key aspects:

• Timing of the events and triggers of dizziness to develop a differential diagnosis 2, 3, 4
• Patient's history, including the quality of symptoms, although patients may have difficulty describing this 2, 3, 5
• Physical examination, including:
  • Orthostatic blood pressure measurement 2, 3
  • Full cardiac and neurologic examination 2, 3
  • Assessment for nystagmus 2, 3
  • Dix-Hallpike maneuver for patients with triggered dizziness 2, 3
  • HINTS (head-impulse, nystagmus, test of skew) examination when indicated 2, 3

Differential Diagnosis

The differential diagnosis for dizziness is broad and includes:

• Peripheral causes, which can cause significant morbidity but are generally less concerning 2, 3
• Central causes, which are more urgent 2, 3
• Benign paroxysmal positional vertigo, which can be treated with canalith repositioning procedures (e.g., Epley maneuver) 2, 3
• Meniere disease, which can be treated with salt restriction and diuretics 3
• Vestibular neuritis, which can be treated with vestibular suppressant medications and vestibular rehabilitation 3

Laboratory Testing and Imaging

Laboratory testing and imaging are usually not required but can be helpful in certain cases 2, 3, 5. A timing-and-triggers approach can be used to characterize the patient's vestibular symptoms and guide further evaluation 4.