What is the initial workup, diagnostics, differential diagnosis, and treatment for a patient presenting with dizziness and nausea?

From the Guidelines

The initial workup for dizziness and nausea should begin with a thorough history and physical examination to distinguish between peripheral and central causes, as recommended by the American Academy of Otolaryngology-Head and Neck Surgery 1.

Key Diagnostics and Differentials

Key diagnostics include:

• Orthostatic vital signs
• Neurological examination
• Dix-Hallpike maneuver
• Audiometry Laboratory tests should include:
• CBC
• Electrolytes
• Glucose
• Thyroid function Imaging such as CT or MRI may be necessary if central causes are suspected. Common differentials include:
• Benign paroxysmal positional vertigo (BPPV)
• Vestibular neuritis
• Meniere's disease
• Medication side effects
• Orthostatic hypotension
• More serious conditions like stroke or intracranial masses

Treatment Options

For BPPV, the Epley maneuver is first-line treatment, as supported by the clinical practice guideline: benign paroxysmal positional vertigo (update) executive summary 1. Vestibular neuritis may require vestibular suppressants like meclizine 25mg every 4-6 hours or diazepam 2-5mg every 8 hours for 3-5 days, along with antiemetics such as ondansetron 4-8mg every 8 hours. Meniere's disease often responds to low-salt diet, diuretics like hydrochlorothiazide 25mg daily, and sometimes betahistine 16mg three times daily. Orthostatic hypotension requires hydration, salt intake, compression stockings, and possibly midodrine 2.5-10mg three times daily. Medication-induced dizziness necessitates review and possible adjustment of offending agents. Acute management should focus on symptom control while addressing the underlying cause. Patients should be advised to move slowly, avoid sudden position changes, stay hydrated, and seek immediate medical attention if experiencing severe headache, focal neurological deficits, or persistent vomiting, as these may indicate more serious conditions requiring urgent intervention.

From the Research

Initial Workup and Diagnostics

• The initial workup for dizziness involves focusing on the timing of events and triggers of dizziness to develop a differential diagnosis 2, 3, 4.
• A physical examination may include orthostatic blood pressure measurement, a full cardiac and neurologic examination, assessment for nystagmus, the Dix-Hallpike maneuver, and 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, 4.

Differentials

• The differential diagnosis for dizziness is broad and includes peripheral and central causes 2, 3, 4.
• Peripheral etiologies can cause significant morbidity but are generally less concerning, whereas central etiologies are more urgent 2, 4.
• Common causes of dizziness include benign paroxysmal positional vertigo, vestibular neuritis, Meniere disease, and vestibular migraine 3, 4, 5.

Treatments

• The treatment for dizziness is dependent on the etiology of the symptoms 2, 5.
• Canalith repositioning procedures (e.g., Epley maneuver) are the most helpful in treating benign paroxysmal positional vertigo 2, 4, 5.
• Vestibular rehabilitation is helpful in treating many peripheral and central etiologies 2, 5.
• Pharmacologic intervention is limited because it often affects the ability of the central nervous system to compensate for dizziness 2, 5.
• Treatment options may also include medication, vestibular physiotherapy, ergotherapy, and rehabilitation, as well as surgical interventions in some cases 5, 6.