What is the approach to a patient presenting with dizziness?

Approach to the Patient with Dizziness

The diagnostic approach to dizziness should begin with categorizing the symptom into one of four types: vertigo, disequilibrium, presyncope, or lightheadedness, followed by targeted testing based on this classification to determine the underlying cause. 1

Initial Assessment

Step 1: Categorize the Type of Dizziness

• Vertigo: Sensation of spinning or false motion (patient or environment)
• Disequilibrium: Imbalance with gait instability
• Presyncope: Nearly fainting or blacking out
• Lightheadedness: Nonspecific vague sensation

Step 2: Characterize the Timing and Triggers

• Episodic vs. continuous
• Duration of episodes (seconds, minutes, hours, days)
• Triggers (positional changes, specific movements, standing)
• Associated symptoms (hearing loss, tinnitus, headache, neurological symptoms)

Diagnostic Approach by Dizziness Type

For Suspected Vertigo

1. Perform the Dix-Hallpike maneuver:

   • Position patient seated upright, rotate head 45° to one side
   • Quickly move patient to supine position with head hanging 20° below horizontal
   • Observe for nystagmus (latency of 5-20 seconds, lasting <60 seconds)
   • Repeat on opposite side 1

2. Perform HINTS examination (for acute vestibular syndrome):

   • Head Impulse test
   • Nystagmus evaluation
   • Test of Skew 2

3. Distinguish peripheral vs. central causes:

   • Peripheral: Benign paroxysmal positional vertigo (BPPV), vestibular neuritis, Meniere's disease, labyrinthitis
   • Central: Stroke, multiple sclerosis, tumors (require immediate attention) 1

For Suspected Presyncope

1. Perform orthostatic blood pressure testing
2. Medication review (antihypertensives, antidepressants, sedatives)
3. Cardiac evaluation if indicated (ECG, cardiac monitoring)

For Disequilibrium

1. Evaluate for neurological disorders (Parkinson's disease, diabetic neuropathy)
2. Assess proprioception and vision
3. Evaluate gait and balance

For Lightheadedness

1. Screen for psychiatric disorders (anxiety, depression, hyperventilation)
2. Consider metabolic causes (hypoglycemia, electrolyte abnormalities)

Management Based on Diagnosis

For BPPV

• Perform canalith repositioning procedure (Epley maneuver) 1
• Consider vestibular rehabilitation (option for initial treatment) 1
• Reassess within 1 month after treatment to confirm resolution 1

For Vestibular Neuritis

• Consider steroid treatment 3
• Vestibular rehabilitation

For Meniere's Disease

• Consider intratympanic dexamethasone or gentamicin 3
• Salt restriction and diuretics

For Symptomatic Relief of Vertigo

• Meclizine 25-100 mg daily in divided doses 4
  • Caution: May cause drowsiness; avoid alcohol and operating machinery
  • Use with caution in patients with asthma, glaucoma, or prostate enlargement

Special Considerations

Modifying Factors Requiring Additional Attention

• Impaired mobility or balance
• CNS disorders
• Lack of home support
• Increased risk for falling 1

Red Flags Requiring Urgent Evaluation

• Sudden severe headache
• Focal neurological deficits
• New-onset vertigo in patients with stroke risk factors
• Vertical nystagmus

For Chronic Dizziness

• Identify and treat any ongoing original cause 5
• Evaluate for impediments to central vestibular compensation:
  • Visual problems
  • Proprioceptive deficits
  • Fear of falling
  • Psychological disorders
• Reduce or discontinue vestibular suppressants when possible 5
• Implement multidisciplinary rehabilitation 6

Patient Education and Follow-up

• Counsel patients about fall risk and home safety
• Warn about potential for recurrence (5-13.5% at 6 months, 10-18% at 1 year, up to 36% long-term) 1
• Educate about importance of follow-up
• Advise about medication side effects (especially drowsiness with meclizine) 4

Remember that approximately 20% of dizzy patients may not receive a definitive diagnosis despite thorough evaluation 3. In these cases, symptomatic management and addressing functional impairment should be prioritized.