What is the 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 underlying causes. According to the most recent and highest quality study 1, a comprehensive approach is essential to identify the underlying cause of dizziness. This approach includes:

• A detailed history to distinguish between different types of dizziness
• Physical examination, including vital signs, orthostatic blood pressure measurements, neurological assessment, and otoscopic examination
• Laboratory tests, such as complete blood count, basic metabolic panel, thyroid function tests, and blood glucose measurement
• An electrocardiogram to detect cardiac arrhythmias
• Specialized tests, like the Dix-Hallpike maneuver for benign paroxysmal positional vertigo, as recommended by 1
• Neuroimaging with CT or MRI if central nervous system pathology is suspected, particularly with accompanying neurological symptoms
• Additional tests, such as audiometry for hearing-related dizziness, carotid ultrasound for vascular causes, and vestibular function tests for inner ear disorders

It is essential to note that the diagnosis of Meniere's disease, as outlined in 1, involves a history of symptoms, including vertigo, fluctuating hearing loss, tinnitus, and aural fullness. The diagnosis of benign paroxysmal positional vertigo, as outlined in 1, involves a history of brief episodes of vertigo associated with head movements and a positive Dix-Hallpike test.

A step-wise approach to the workup of dizziness is crucial to minimize unnecessary testing and to ensure that the underlying cause is identified and treated appropriately, as emphasized by 1. This approach prioritizes the patient's morbidity, mortality, and quality of life, and is supported by the latest evidence from 1, which provides an updated guideline for the evaluation and management of dizziness and ataxia.

From the Research

Work-up for Dizziness

The work-up for dizziness typically 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 often have difficulty describing the quality of their symptoms 2, 3.
• 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, 3.
• Laboratory testing and imaging are usually not required, but can be helpful in certain cases 2, 3.

Differential Diagnosis

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

• Peripheral etiologies can cause significant morbidity, but are generally less concerning, whereas central etiologies are more urgent 2, 3.
• Common causes of dizziness include:
  • Benign paroxysmal positional vertigo (BPPV)
  • Meniere disease
  • Vestibular neuritis
  • Post-exposure acute vestibular syndrome (AVS)
  • Spontaneous AVS
  • Triggered episodic vestibular syndrome (EVS)
  • Spontaneous EVS 2, 4.

Treatment

The treatment for dizziness depends on the underlying cause of the symptoms.

• Canalith repositioning procedures (e.g., Epley maneuver) are often used to treat BPPV 2, 3.
• Vestibular rehabilitation can be helpful in treating many peripheral and central etiologies 3.
• Other etiologies of dizziness require specific treatment to address the cause, and pharmacologic intervention is limited due to its potential to affect the central nervous system's ability to compensate for dizziness 3.