What is the initial approach to evaluate dizziness?

Initial Approach to Evaluate Dizziness

The initial evaluation of dizziness should focus on timing and triggers rather than symptom quality, including a targeted history, physical examination with orthostatic blood pressure measurements, neurological assessment, and a 12-lead ECG. 1, 2

Diagnostic Framework

Step 1: Categorize Based on Timing and Triggers

Categorize dizziness into one of three patterns:

1. Acute Vestibular Syndrome (continuous dizziness)

   • Perform HINTS examination (Head-Impulse, Nystagmus, Test of Skew)
   • Abnormal HINTS or neurological deficits warrant MRI brain without contrast 1

2. Spontaneous Episodic Vestibular Syndrome (recurrent unprovoked episodes)

   • Evaluate for associated symptoms (hearing loss, tinnitus, headache)
   • Consider Menière's disease, vestibular migraine, or TIA

3. Triggered Episodic Vestibular Syndrome (episodes with specific triggers)

   • Perform Dix-Hallpike maneuver for positional triggers
   • Positive test suggests BPPV 1, 3

Step 2: Key Physical Examination Components

• Orthostatic blood pressure measurements 2, 1
• Cardiovascular examination
• Neurological examination
• Assessment for nystagmus
• Dix-Hallpike maneuver (for triggered dizziness)

Step 3: Targeted Testing

• 12-lead ECG (part of initial evaluation) 2
• Avoid routine neuroimaging for typical BPPV 1
• MRI brain (without contrast) indicated for:
  • Acute vestibular syndrome with abnormal HINTS
  • Neurological deficits
  • High vascular risk with acute vestibular syndrome
  • Chronic undiagnosed dizziness not responding to treatment 1

Common Diagnoses and Management

Peripheral Causes (35-55% of cases)

• BPPV: Treat with canalith repositioning procedures (Epley maneuver) 1, 3
• Menière's Disease: Salt restriction, diuretics 3
• Vestibular Neuritis: Vestibular suppressants, vestibular rehabilitation 3

Central Causes

• Stroke/TIA: Urgent neurological evaluation if suspected
• Migraine-associated Vertigo: Migraine prophylaxis

Other Common Causes

• Orthostatic Hypotension: Hydration, medication adjustment, alpha agonists 4
• Psychiatric Disorders: Address underlying anxiety or depression 4

Important Caveats

1. Avoid overreliance on symptom quality (vertigo, presyncope, disequilibrium, lightheadedness) as this approach has limited clinical usefulness 1, 3, 5

2. Laboratory testing is rarely helpful unless directed by specific clinical suspicion 1, 6

3. Neuroimaging should not be routine but reserved for specific indications 1

4. Medication review is essential as many drugs can cause dizziness, particularly in cases of presyncope 4

5. About 20% of cases remain undiagnosed despite thorough evaluation 6

6. Meclizine is only indicated for vertigo associated with vestibular system diseases, not for all types of dizziness 7

7. Vestibular rehabilitation is beneficial for many peripheral and central causes of chronic dizziness 1, 3

By following this structured approach focusing on timing and triggers rather than symptom quality, clinicians can more effectively evaluate dizziness and reduce unnecessary testing while improving diagnostic accuracy.