What is the initial workup for a patient presenting with lightheadedness?

From the Guidelines

The initial workup for a patient presenting with lightheadedness should consist of a careful history, physical examination, including orthostatic BP measurements, and electrocardiogram (ECG) as outlined in the guidelines for the diagnosis and management of syncope 1. The evaluation should focus on answering three key questions:

• Is it a syncopal episode or not?
• Has the aetiological diagnosis been determined?
• Are there data suggestive of a high risk of cardiovascular events or death? Based on these findings, additional examinations may be performed, such as:
• Carotid sinus massage (CSM) in patients over 40 years
• Echocardiogram when there is previous known heart disease or data suggestive of structural heart disease or syncope secondary to cardiovascular cause
• Immediate ECG monitoring when there is a suspicion of arrhythmic syncope
• Orthostatic challenge (lying-to-standing orthostatic test and/or head-up tilt testing) when syncope is related to the standing position or there is a suspicion of a reflex mechanism Other less specific tests such as neurological evaluation or blood tests are only indicated when there is suspicion of non-syncopal T-LOC, as recommended by the guidelines 1. Key aspects of the initial evaluation include:
• A thorough history to identify potential causes of lightheadedness
• Physical examination, including orthostatic BP measurements to assess for orthostatic hypotension
• ECG to identify arrhythmias or conduction abnormalities By following this approach, clinicians can effectively evaluate patients presenting with lightheadedness and guide appropriate treatment, as suggested by the guidelines for the diagnosis and management of syncope 1.

From the FDA Drug Label

The FDA drug label does not answer the question.

From the Research

Initial Workup for Lightheadedness

The initial workup for a patient presenting with lightheadedness involves a thorough evaluation to determine the underlying cause. Some key considerations include:

• Taking a detailed medical history to identify potential causes of lightheadedness, such as orthostatic hypotension, cardiac arrhythmias, or neurological disorders 2, 3
• Performing a physical examination, including orthostatic vital signs, to assess for signs of orthostatic hypotension or other conditions that may be contributing to lightheadedness 2, 3
• Using diagnostic tests, such as 24-hour Holter monitoring, to evaluate for cardiac arrhythmias or other conditions that may be causing lightheadedness 4
• Considering the timing and triggers of the lightheadedness, as well as associated symptoms, to guide the differential diagnosis and targeted bedside examination protocol 5

Diagnostic Approach

A new diagnostic approach to the adult patient with acute dizziness, which includes lightheadedness, emphasizes different aspects of the history to guide a focused physical examination 5. This approach divides patients into three key categories using timing and triggers:

• Acute vestibular syndrome, where bedside physical examination differentiates vestibular neuritis from stroke
• Spontaneous episodic vestibular syndrome, where associated symptoms help differentiate vestibular migraine from transient ischemic attack
• Triggered episodic vestibular syndrome, where the Dix-Hallpike and supine roll test help differentiate benign paroxysmal positional vertigo from posterior fossa structural lesions

Orthostatic Hypotension

Orthostatic hypotension (OH) is a common condition that can cause lightheadedness, and is associated with an increased risk of mild cognitive impairment and dementia in patients with Parkinson's disease 6. The diagnosis of OH is typically made using consensus-based criteria, but clinically significant OH, defined as a mean arterial pressure (MAP) in standing position ≤75 mmHg, may be a stronger predictor of cognitive decline 6.

Key Considerations

Some key considerations in the initial workup for lightheadedness include:

• The patient's medical history and physical examination findings
• The use of diagnostic tests, such as 24-hour Holter monitoring, to evaluate for cardiac arrhythmias or other conditions
• The timing and triggers of the lightheadedness, as well as associated symptoms, to guide the differential diagnosis and targeted bedside examination protocol
• The potential for orthostatic hypotension, and the use of consensus-based criteria or clinically significant OH to diagnose this condition 2, 3, 6