From the Guidelines
The initial workup for a patient presenting with dizziness should begin with a thorough history and physical examination to distinguish between vertigo, presyncope, disequilibrium, and lightheadedness. Ask about onset, duration, triggers, associated symptoms (hearing loss, tinnitus, nausea, vomiting), and medication use. Vital signs should be measured, including orthostatic blood pressure readings (supine, then standing after 1-3 minutes). A complete neurological examination is essential, including cranial nerves, cerebellar function, and special tests like the Dix-Hallpike maneuver for benign paroxysmal positional vertigo (BPPV) and the head impulse test for vestibular dysfunction, as recommended by the clinical practice guideline for BPPV 1.
Key Components of the Initial Workup
- History: onset, duration, triggers, associated symptoms
- Physical examination: vital signs, neurological examination, special tests (Dix-Hallpike maneuver, head impulse test)
- Laboratory tests: complete blood count, basic metabolic panel, glucose measurement
- Cardiovascular examination: assess for arrhythmias or murmurs
- Audiometry: consider with hearing complaints
According to the ACR Appropriateness Criteria for dizziness and ataxia, for patients with acute persistent vertigo and a normal neurologic examination, imaging may not be required if the HINTS examination by specially trained providers is available and negative 1. However, for patients with concerning neurological symptoms, persistent vertigo, or risk factors for stroke, brain imaging (CT or MRI) may be necessary. This systematic approach helps identify the underlying cause of dizziness, which ranges from benign conditions like BPPV to more serious disorders such as stroke or cardiac arrhythmias, allowing for appropriate management.
Considerations for Imaging
- HINTS examination: useful in distinguishing between peripheral and central causes of vertigo
- Brain imaging (CT or MRI): consider for patients with concerning neurological symptoms, persistent vertigo, or risk factors for stroke
- ACR Appropriateness Criteria: provides guidance on the use of imaging in patients with dizziness and ataxia 1
From the FDA Drug Label
Meclizine hydrochloride tablets are indicated for the treatment of vertigo associated with diseases affecting the vestibular system in adults. The FDA drug label does not answer the question.
From the Research
Initial Workup for Dizziness
The initial workup for a patient presenting with dizziness involves a thorough medical history, physical examination, and assessment of the timing and triggers of the dizziness 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
Laboratory Testing and Imaging
Laboratory testing and imaging are usually not required but can be helpful in certain cases 2, 3.
- Orthostatic vital sign measurement (OVSM) can be used to diagnose orthostatic intolerance (OI) 4
- Autonomic function tests (AFTs) can be used to diagnose postural orthostatic tachycardia syndrome (POTS) 5
- Magnetic resonance imaging (MRI) brain can be used to rule out central causes of dizziness 5, 6
Differential Diagnosis
The differential diagnosis for dizziness is broad and includes peripheral and central causes 2, 3.
- Peripheral etiologies can cause significant morbidity but are generally less concerning
- Central etiologies are more urgent and require immediate attention
- Common causes of dizziness include:
- Benign paroxysmal positional vertigo (BPPV)
- Meniere disease
- Vestibular neuritis
- Orthostatic hypotension (OH)
- Postural orthostatic tachycardia syndrome (POTS)
- Vasovagal syncope
- Fluid and electrolyte disorders
- Circulatory/pulmonary causes
- Central vascular causes 6