What is the initial approach to evaluating a patient presenting with dizziness?

Initial Approach to Evaluating Dizziness

The initial approach to evaluating dizziness should focus on timing and triggers rather than symptom quality, with specific diagnostic maneuvers like the Dix-Hallpike test for positional vertigo, orthostatic vital signs for presyncope, and the HINTS examination for acute vestibular syndrome to distinguish peripheral from central causes. 1

Diagnostic Framework: Timing and Triggers Approach

The most effective approach to evaluating dizziness categorizes patients into three groups based on timing and triggers, rather than relying on symptom quality descriptions:

1. Acute Vestibular Syndrome (AVS) - Continuous dizziness lasting days

   • Perform HINTS examination (Head-Impulse, Nystagmus, Test of Skew)
   • Normal HINTS suggests peripheral cause (vestibular neuritis)
   • Abnormal HINTS suggests central cause (stroke) 1

2. Spontaneous Episodic Vestibular Syndrome - Recurrent episodes without clear trigger

   • Assess for associated symptoms (hearing loss, tinnitus, headache)
   • Menière's disease: episodes with hearing loss, tinnitus, aural fullness
   • Vestibular migraine: history of migraine, photophobia 1

3. Triggered Episodic Vestibular Syndrome - Episodes provoked by specific triggers

   • Perform Dix-Hallpike maneuver for suspected BPPV
   • Positive test: vertigo with torsional, upbeating nystagmus 1

Essential Components of Initial Evaluation

History

• Timing: onset, duration, frequency
• Triggers: positional changes, head movements, specific situations
• Associated symptoms: hearing loss, tinnitus, headache, neurological deficits
• Medication review: sedatives, antihypertensives, muscle relaxants 1

Physical Examination

• Orthostatic vital signs: measure BP and HR supine, sitting, and standing
• Neurological examination: cranial nerves, cerebellar function, gait
• Vestibular testing:
  • Dix-Hallpike maneuver (position patient from upright to supine with head turned 45° to one side and neck extended 20°)
  • HINTS examination for acute vestibular syndrome 1

Red Flags Requiring Immediate Attention

• Sudden severe headache with dizziness
• New neurological symptoms
• Inability to walk or stand
• Persistent vomiting with dizziness
• Somnolence or altered mental status 1

Diagnostic Testing

• Imaging: Reserve for cases with abnormal neurological findings or concerning features

  • MRI brain is preferred for suspected central vertigo
  • No imaging necessary for typical BPPV with positive Dix-Hallpike test 1

• Laboratory testing: Generally limited role in initial evaluation

  • Consider renal function assessment if medication-related dizziness is suspected 2

Common Causes and Initial Management

Benign Paroxysmal Positional Vertigo (BPPV)

• Diagnosis: Positive Dix-Hallpike test
• Treatment: Canalith repositioning procedure (Epley maneuver)
• Note: Postprocedural restrictions not recommended 1

Vestibular Neuritis

• Presentation: Sudden, severe vertigo lasting days with unidirectional horizontal nystagmus
• Treatment: Brief use of vestibular suppressants and vestibular rehabilitation 1

Orthostatic Hypotension

• Diagnosis: Drop in BP (≥20 mmHg systolic or ≥10 mmHg diastolic) upon standing
• Treatment: Address underlying causes, consider midodrine for refractory cases
• Caution: Monitor for supine hypertension with midodrine use 2

Menière's Disease

• Presentation: Episodic vertigo with hearing loss, tinnitus, and aural fullness
• Treatment: Low-salt diet, diuretics, intratympanic medications for refractory cases 1

Pitfalls to Avoid

• Overreliance on symptom quality: The traditional approach of categorizing dizziness as vertigo, presyncope, disequilibrium, or lightheadedness has limited clinical usefulness 3, 4

• Overuse of vestibular suppressant medications: Can delay central compensation and is not recommended for long-term use 1

• Missing central causes: Failure to perform appropriate examinations like HINTS in acute vestibular syndrome can lead to missed stroke diagnosis 1, 5

• Unnecessary imaging: Routine imaging is not indicated for typical peripheral vestibular disorders with characteristic presentations 1, 6

• Medication-induced dizziness: Failing to review medications that can cause or exacerbate dizziness (sedatives, antihypertensives, cardiac glycosides) 1, 2

By following this structured approach based on timing and triggers, clinicians can efficiently evaluate patients with dizziness, distinguish between benign peripheral and serious central causes, and implement appropriate management strategies.