What is the workup for a patient presenting with lightheadedness?

Workup for Lightheadedness

The workup for lightheadedness should begin with categorizing the symptom into one of four types: vertigo, presyncope, disequilibrium, or non-specific lightheadedness, followed by targeted history, examination, and testing based on this initial classification. 1

Initial Assessment and Classification

Lightheadedness is a common symptom that can represent various underlying conditions ranging from benign to life-threatening. The first step is to classify the type of lightheadedness:

1. Vertigo: Sensation of spinning or movement
2. Presyncope: Feeling of impending faint
3. Disequilibrium: Unsteadiness when standing/walking
4. Non-specific lightheadedness: Vague symptoms not fitting other categories

Key History Elements

• Timing and triggers: Positional changes, specific movements, time of day 2
• Associated symptoms: Palpitations, sweating, nausea, hearing changes, visual disturbances 2
• Duration: Seconds, minutes, hours
• Medication review: Antihypertensives, vasodilators, diuretics 2
• Cardiac history: Known arrhythmias, heart failure, valvular disease 2
• Neurological symptoms: Focal weakness, speech changes, coordination issues

Physical Examination

Vital Signs

• Orthostatic vital signs: Measure BP and HR supine, then after standing for 1-3 minutes
  • Classic orthostatic hypotension: ≥20 mmHg drop in systolic BP within 3 minutes 2
  • Delayed orthostatic hypotension: BP drop after >3 minutes 3
  • POTS: HR increase ≥30 bpm (≥40 bpm in 12-19 years) within 10 minutes without OH 2

Cardiovascular Examination

• Heart sounds, murmurs (outflow obstruction)
• Signs of heart failure (elevated JVP, edema, crackles)
• Carotid bruits

Neurological Examination

• Nystagmus: Direction, triggers
• Dix-Hallpike maneuver: For suspected BPPV 2
• Gait and balance assessment: For disequilibrium
• Cranial nerve examination: Particularly CN VIII

Diagnostic Testing

First-Line Testing

• 12-lead ECG: For all patients with suspected cardiac causes 2
  • Look for: Conduction disorders, arrhythmias, ischemic changes

Second-Line Testing (Based on Initial Classification)

• Presyncope/Cardiac Suspected:

  • Ambulatory cardiac monitoring (24-hour to 30-day based on frequency) 2
  • Echocardiography if structural heart disease suspected 2
  • Tilt-table testing for recurrent unexplained syncope 2

• Vertigo Suspected:

  • Audiometry if hearing symptoms present
  • Vestibular testing for persistent symptoms

• Orthostatic Hypotension:

  • Extended standing test (up to 30 minutes) for delayed OH 3
  • Basic metabolic panel, CBC (anemia, dehydration)

• Non-specific/Psychiatric:

  • Consider psychiatric evaluation for anxiety, depression, hyperventilation 1

Special Populations

Elderly Patients

• Higher risk of polypharmacy effects
• More likely to have multifactorial causes
• More prone to orthostatic hypotension 2

Pediatric Patients

• Different HR criteria for POTS (≥40 bpm increase) 2
• Consider congenital heart disease
• VVS more common 2

Treatment Approaches

Treatment depends on the underlying cause:

• Orthostatic Hypotension:

  • Fluid resuscitation for dehydration 2
  • Increased salt and fluid intake 2
  • Consider midodrine for persistent symptoms 4
  • Reduce or withdraw medications causing hypotension 2

• POTS:

  • Increased fluid/salt intake
  • Exercise reconditioning
  • Compression garments

• Vertigo:

  • Canalith repositioning (Epley maneuver) for BPPV 2
  • Vestibular rehabilitation

• Cardiac Causes:

  • Specific treatment based on underlying condition
  • Pacemaker for symptomatic bradyarrhythmias 2

Common Pitfalls to Avoid

• Inadequate orthostatic testing: Standard 3-minute testing may miss delayed orthostatic hypotension
• Overlooking medication effects: Always review medication list thoroughly
• Premature cardiac focus: Not all lightheadedness is cardiac in origin
• Missing POTS: Requires specific testing for heart rate changes with positional changes
• Incomplete neurological exam: Missing subtle neurological findings

Remember that approximately 20% of cases may remain without a definitive diagnosis despite thorough evaluation 1. In these cases, symptomatic treatment and close follow-up are appropriate.