From the Guidelines
The workup for dizziness should begin with a careful history to distinguish between vertigo, lightheadedness, disequilibrium, or presyncope, as this guides further evaluation. According to the most recent and highest quality study 1, a thorough history and physical examination are essential in evaluating patients with dizziness. The history should evaluate for neurologic, other neurotologic/otologic, oncologic, inflammatory, or infectious or vascular causes.
Key Components of the Workup
- Start with vital signs, including orthostatic measurements
- Perform a focused neurological examination including the HINTS exam (Head Impulse, Nystagmus, Test of Skew) for suspected vertigo
- Laboratory testing should include complete blood count, basic metabolic panel, thyroid function tests, and blood glucose
- For persistent or concerning symptoms, consider an electrocardiogram to rule out cardiac causes
- Imaging studies such as CT or MRI of the brain are indicated for patients with focal neurological deficits, new-onset severe headache, or risk factors for cerebrovascular disease
Specialized Testing
- Audiometry for hearing loss
- Vestibular function tests like electronystagmography for suspected peripheral vestibular disorders
- Dix-Hallpike maneuver for benign paroxysmal positional vertigo
- For recurrent unexplained dizziness, consider 24-hour Holter monitoring or longer-term cardiac event monitoring
Consultation with Specialists
Consultation with specialists (neurology, ENT, cardiology) should be pursued based on the suspected etiology. This comprehensive approach is necessary because dizziness can result from multiple systems including vestibular, neurological, cardiovascular, metabolic, or medication-related causes, and proper diagnosis requires systematic evaluation of these potential etiologies, as noted in 1 and 1.
From the Research
Diagnostic Approach
The diagnostic approach for a patient presenting with dizziness (vertigo) involves a thorough medical history, physical examination, and vestibular function tests to identify the etiology of the dizziness 2. The following steps can be taken:
- Take a detailed medical history to determine if the dizziness is acute or chronic, episodic or continuous, or evoked by or brought on by an event or circumstance 3
- Perform a systematic physical examination, including the head impulse (Halmagyi) test, test for nystagmus, and the test of skew 4
- Use positional tests, such as the Dix-Hallpike maneuver, to diagnose benign paroxysmal positional vertigo (BPPV) 2, 4
- Consider orthostatic testing, such as orthostatic vital sign measurement (OVSM) or head-up tilt table test, to diagnose orthostatic intolerance (OI) 2
Diagnostic Tests
The following diagnostic tests can be used to evaluate a patient with dizziness:
- Vestibular function tests to identify peripheral vestibular disorders 5
- Magnetic resonance imaging (MRI) scan to confirm a central cause of vertigo 4
- Orthostatic vital sign measurement (OVSM) or head-up tilt table test to diagnose OI 2
Patient Management
Patient management tactics for dizziness include:
- Symptomatic therapy for patients with a peripheral cause of vertigo, with advice to consult an ear, nose, and throat physician 4
- Further neurological treatment for patients with a central cause of vertigo, who should be admitted for observation 4
- Use of betahistyn hydrochloride for treatment of various types of vestibulopathy and prevention of attacks 6