From the Guidelines
A comprehensive history of present illness (HPI) for a patient presenting with vertigo should include the onset, duration, character, associated symptoms, aggravating/alleviating factors, and prior treatments, as this information is crucial in distinguishing between peripheral, central, and systemic causes of vertigo, as noted in the clinical practice guideline for benign paroxysmal positional vertigo (BPPV) 1. When evaluating a patient with vertigo, it is essential to document the following key elements:
- Onset: When did the dizziness start, and was it sudden or gradual?
- Duration: How long do the episodes last, and are they constant or episodic?
- Character: Is the sensation vertigo (spinning), lightheadedness, imbalance, or presyncope (feeling faint)?
- Associated symptoms: Are there any accompanying symptoms such as nausea, vomiting, hearing changes, tinnitus, headache, visual disturbances, or neurological symptoms?
- Aggravating/alleviating factors: What triggers or relieves the dizziness, such as position changes, head movements, or specific activities?
- Prior treatments: Have there been any previous evaluations or treatments for dizziness, and were they effective? This detailed history helps to differentiate between various causes of vertigo, including peripheral causes like BPPV and Meniere's disease, central causes like stroke and multiple sclerosis, and systemic causes like medication effects and orthostatic hypotension, as outlined in the guideline 1. The clinical practice guideline for BPPV emphasizes the importance of taking a thorough history to diagnose and manage vertigo effectively, highlighting the need to consider the timing and triggers of the patient's symptoms, as well as any associated medical conditions or medications that may be contributing to the vertigo 1. In addition to the HPI, the guideline recommends using the Dix-Hallpike maneuver and the supine roll test to diagnose BPPV and distinguish it from other causes of vertigo, as these tests can help identify the characteristic nystagmus and vertigo associated with BPPV 1. By following this approach, clinicians can develop an effective treatment plan for patients with vertigo, whether it involves repositioning maneuvers for BPPV, vestibular rehabilitation, or management of underlying medical conditions, ultimately improving patient outcomes and reducing the risk of complications like falls and injuries.
From the FDA Drug Label
The FDA drug label does not answer the question.
From the Research
History of Present Illness (HPI) for Vertigo
The HPI for a patient presenting with vertigo (dizziness) involves categorizing the symptom into one of four categories: vertigo, presyncope, disequilibrium, or lightheadedness 2, 3. The patient's history can help identify the timing and triggers of the symptom, which is crucial in determining the underlying cause.
Key Components of HPI
- The quality of the symptom: patients have difficulty describing the quality of their symptoms, but can more consistently identify the timing and triggers 2
- Timing: episodic vertigo triggered by head motion may be due to benign paroxysmal positional vertigo 2
- Triggers: vertigo with unilateral hearing loss suggests Meniere disease, while episodic vertigo not associated with any trigger may be a symptom of vestibular neuritis 2
Physical Examination and Diagnostic Tests
The physical examination includes:
- Orthostatic blood pressure measurement
- A full cardiac and neurologic examination
- Assessment for nystagmus
- The Dix-Hallpike maneuver 2, 3
- The HINTS (head-impulse, nystagmus, test of skew) examination to help distinguish peripheral from central etiologies 2
Differential Diagnosis
The differential diagnosis of dizziness can be narrowed with easy-to-perform physical examination tests, including evaluation for nystagmus, the Dix-Hallpike maneuver, and orthostatic blood pressure testing 3. The main causes of vertigo are:
- Benign paroxysmal positional vertigo
- Meniere disease
- Vestibular neuritis
- Labyrinthitis 3