From the Guidelines
The workup for a patient presenting with dizziness (vertigo) should begin with a detailed history and physical examination to distinguish between vertigo, disequilibrium, presyncope, and non-specific dizziness, and should include the Dix-Hallpike maneuver to evaluate for benign paroxysmal positional vertigo (BPPV) as recommended by the clinical practice guideline: benign paroxysmal positional vertigo (update) executive summary 1. The history should ask about onset, duration, triggers, associated symptoms like hearing loss or neurological symptoms, and medication use.
- Vital signs should be checked, including orthostatic measurements.
- A focused neurological examination should assess cranial nerves, cerebellar function.
- Basic laboratory tests include complete blood count, electrolytes, glucose, thyroid function, and vitamin B12 levels.
- Electrocardiogram (ECG) is recommended to rule out cardiac causes. For persistent or concerning symptoms, additional testing may include:
- Audiometry
- Vestibular function tests
- Brain imaging (CT or MRI)
- Carotid ultrasound MRI is preferred when neurological symptoms are present. Referral to specialists like ENT, neurology, or cardiology may be necessary depending on the suspected cause. The comprehensive approach is important because dizziness can result from various systems including vestibular, neurological, cardiovascular, metabolic, or medication-related causes, and proper diagnosis guides appropriate treatment, as outlined in the clinical practice guideline: ménière's disease 1. It is also important to differentiate BPPV from other causes of imbalance, dizziness, and vertigo, as recommended by the clinical practice guideline: benign paroxysmal positional vertigo (update) executive summary 1. Clinicians should diagnose posterior semicircular canal BPPV when vertigo associated with torsional, upbeating nystagmus is provoked by the Dix-Hallpike maneuver, as stated in the guideline 1. The Dix-Hallpike test is a crucial component of the physical examination, as it can help diagnose BPPV, which is a common cause of vertigo, as discussed in the clinical practice guideline: benign paroxysmal positional vertigo (update) 1.
From the Research
Workup for Dizziness (Vertigo)
The workup for a patient presenting with dizziness (vertigo) involves a thorough evaluation to determine the underlying cause. The following steps are recommended:
- Focus on the timing of the events and triggers of dizziness to develop a differential diagnosis 2, 3
- Perform a physical examination, including:
- Laboratory testing and imaging are usually not required but can be helpful in certain cases 2, 3, 4
- Consider the use of bedside tests, such as the Dix-Hallpike test, to diagnose benign paroxysmal positional vertigo (BPPV) 5
- Treatment depends on the etiology of the symptoms, and may include canalith repositioning procedures (e.g., Epley maneuver) for BPPV, vestibular rehabilitation, or specific treatment to address the underlying cause 2, 3, 5
Differential Diagnosis
The differential diagnosis for dizziness is broad and includes peripheral and central causes. Peripheral etiologies can cause significant morbidity but are generally less concerning, whereas central etiologies are more urgent 2, 3. Common peripheral causes include:
- Benign paroxysmal positional vertigo (BPPV)
- Meniere disease
- Vestibular neuritis
- Central causes may include vertebrobasilar disease with brain infarction in the posterior fossa 4
Diagnostic Approach
The diagnostic approach should involve a structured interview and a systematic physical examination to identify red flag symptoms that may indicate a central cause of vertigo 4. The HINTS examination can help distinguish peripheral from central etiologies 2, 3, 4. Magnetic resonance imaging (MRI) scan may be necessary to confirm a central cause of vertigo 4.