What is the initial workup and management for a patient presenting with dizziness and lightheadedness?

Initial Workup and Management for Dizziness and Lightheadedness

The initial workup for dizziness and lightheadedness should focus on distinguishing between four main categories: vertigo, presyncope, disequilibrium, and lightheadedness, with targeted testing based on timing and triggers rather than symptom quality.

Classification of Dizziness

Dizziness can be categorized into four main types:

1. Vertigo: False sensation of motion or spinning

   • Characterized by: Rotational sensation, nausea, vomiting, balance problems
   • Common causes: BPPV, vestibular neuritis, Meniere's disease, central causes

2. Presyncope/Orthostatic Intolerance: Near-fainting sensation

   • Characterized by: Lightheadedness upon standing, visual dimming, feeling of impending faint
   • Common causes: Orthostatic hypotension, cardiac arrhythmias, vasovagal reactions

3. Disequilibrium: Unsteadiness or imbalance without vertigo

   • Characterized by: Feeling of imbalance, worse when walking
   • Common causes: Peripheral neuropathy, Parkinson's disease, cerebellar disorders

4. Lightheadedness: Vague sensation of disconnection

   • Characterized by: Vague "floating" sensation, often chronic
   • Common causes: Anxiety, hyperventilation, medication side effects

Diagnostic Approach

1. History Taking - Focus on Timing and Triggers

• Timing patterns:

  • Episodic vs. continuous
  • Duration of episodes (seconds, minutes, hours, days)
  • Onset (sudden vs. gradual)

• Triggers:

  • Positional changes (lying down, rolling over, standing up)
  • Head movements
  • Specific environments (crowds, heights)
  • Exertion
  • Medications

• Associated symptoms:

  • Hearing loss or tinnitus (suggests inner ear disorder)
  • Headache (may suggest vestibular migraine)
  • Neurological symptoms (numbness, weakness, visual changes)
  • Palpitations or chest pain (suggests cardiac cause)
  • Nausea/vomiting (common with vertigo)

2. Physical Examination

• Vital signs:

  • Orthostatic blood pressure and heart rate (supine, then standing after 1-3 minutes)
  • Define orthostatic hypotension as drop in systolic BP ≥20 mmHg or diastolic BP ≥10 mmHg 1

• Cardiovascular examination:

  • Heart rate and rhythm
  • Murmurs or abnormal heart sounds

• Neurological examination:

  • Cranial nerves
  • Motor strength and coordination
  • Gait assessment

• Vestibular assessment:

  • HINTS examination (Head-Impulse, Nystagmus, Test of Skew) for acute vestibular syndrome 2
  • Dix-Hallpike maneuver for suspected BPPV
  • Supine roll test for horizontal canal BPPV

3. Targeted Laboratory Testing

Laboratory tests should be ordered selectively based on clinical suspicion:

• For orthostatic dizziness/presyncope:

  • CBC and electrolytes 2
  • Blood glucose/HbA1c for diabetic patients 2
  • Renal function tests for patients on medications affecting electrolytes 2

• For suspected anemia:

  • Complete blood count 2

4. Imaging

Imaging has low diagnostic yield in isolated dizziness without neurological deficits:

• MRI brain (without contrast) is preferred when imaging is indicated:

  • Acute vestibular syndrome with abnormal HINTS exam
  • Presence of neurological deficits
  • High vascular risk patients with acute vestibular syndrome
  • Chronic undiagnosed dizziness not responding to treatment 2

• CT head has poor sensitivity (28.5%) for central causes and should not be routinely ordered 2

Management Based on Diagnosis

1. Vertigo Management

• BPPV:

  • Canalith repositioning procedure (Epley maneuver) for posterior canal BPPV
  • Roll maneuvers for horizontal canal BPPV 2

• Vestibular neuritis:

  • Short-term vestibular suppressants
  • Vestibular rehabilitation 2

• Meniere's disease:

  • Salt restriction
  • Diuretics 3

2. Presyncope/Orthostatic Hypotension Management

• Initial OH (within 15 seconds of standing):

  • Slow position changes
  • Counter-maneuvers (leg crossing, muscle tensing)

• Classic OH (within 3 minutes of standing):

  • Volume expansion (adequate hydration)
  • Medication adjustment (review vasodilators, diuretics)
  • Alpha agonists or mineralocorticoids for persistent cases 4

• Delayed OH (beyond 3 minutes):

  • Similar to classic OH management
  • May require longer monitoring periods

3. Disequilibrium Management

• Treat underlying cause (e.g., diabetic neuropathy, Parkinson's disease)
• Physical therapy and gait training
• Assistive devices as needed

4. Lightheadedness Management

• Address underlying psychiatric disorders (anxiety, depression)
• Breathing techniques for hyperventilation
• Medication review and adjustment

Red Flags Requiring Urgent Evaluation

• Acute onset severe headache with dizziness (possible subarachnoid hemorrhage)
• Focal neurological deficits (possible stroke)
• Abnormal HINTS examination suggesting central cause 2
• New-onset severe dizziness in patients >65 years with vascular risk factors 5
• Ataxia symptoms (OR=11.39 for central causes) 5
• History of previous stroke (OR=3.89 for central causes) or diabetes mellitus (OR=3.57) 5

Common Pitfalls to Avoid

• Overreliance on imaging: MRI may miss approximately 20% of strokes if performed early 2
• Overuse of vestibular suppressants: Can delay central compensation 2
• Failure to perform appropriate positional testing: Missing BPPV diagnosis 2
• Missing red flags for central causes: Such as neurological symptoms or atypical nystagmus patterns 2
• Inadequate patient education: Leading to poor outcomes and increased fall risk 2

Follow-up Recommendations

• Schedule follow-up to assess treatment effectiveness
• Consider referral to specialists (neurology, ENT, cardiology) for persistent symptoms
• Provide fall prevention counseling, especially for elderly patients
• Inform about recurrence rates (15% per year, up to 50% at 5 years) 2