From the Guidelines
When evaluating a patient with dizziness, clinicians should ask questions that help distinguish between the four main types of dizziness: vertigo, presyncope, disequilibrium, and non-specific dizziness, as recommended by the most recent guidelines 1. To start, ask the patient to describe exactly what they mean by "dizziness" without using that term. Inquire about:
- Onset, duration, and frequency of symptoms
- Triggers like position changes, head movements, or specific situations
- Associated symptoms such as:
- Hearing loss
- Tinnitus
- Nausea
- Vomiting
- Headache
- Neurological symptoms like weakness, numbness, or visual disturbances Medication history is crucial, as many drugs can cause dizziness as a side effect 1. Past medical history questions should focus on:
- Cardiovascular conditions
- Neurological disorders
- Ear problems
- Psychiatric conditions Ask about recent trauma, especially to the head or neck. Lifestyle factors like:
- Alcohol consumption
- Sleep patterns
- Stress levels may contribute to symptoms. Family history of similar symptoms or conditions like migraine or Meniere's disease can provide additional context 1. The goal is to differentiate between peripheral vestibular causes (like BPPV or vestibular neuritis), central causes (like stroke or multiple sclerosis), cardiovascular causes (like orthostatic hypotension), or other etiologies, guiding appropriate diagnostic testing and management, as the most recent and highest quality study suggests 1.
From the Research
Evaluating Dizziness in Patients
When evaluating a patient with dizziness, several key questions can help determine the underlying cause.
- The timing and triggers of dizziness are crucial, as patients often have difficulty describing the quality of their symptoms 2, 3, 4.
- Questions about vertigo, such as episodic vertigo triggered by head motion, can indicate benign paroxysmal positional vertigo (BPPV) 2, 5.
- Inquiries about symptoms like unilateral hearing loss can suggest Meniere disease 2.
- Asking about dizziness when turning in bed can predict examination findings for BPPV 5.
- The duration of dizziness, such as whether it lasts seconds or is continuous, can also be helpful in distinguishing between different causes 5.
Physical Examination and Diagnostic Tests
A physical examination, including:
- 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 can help determine whether the etiology is peripheral or central 2, 3. Laboratory testing and imaging are usually not required but can be helpful in certain cases 2, 3.
Importance of Medical History
Obtaining a careful medical history is essential in evaluating dizziness, as it can help identify potential causes and guide further assessment and management 6. Consulting specialists, such as an audiologist, otolaryngologist, neurologist, cardiologist, and/or psychiatrist, may be necessary depending on the suspected underlying cause 6.