How do you differentiate and manage dizziness versus vertigo?

Differentiating and Managing Dizziness versus Vertigo

The most effective approach to differentiating dizziness from vertigo is to focus on timing and triggers rather than symptom quality, with specific diagnostic maneuvers like the Dix-Hallpike test for vertigo and targeted treatment based on the identified cause. 1

Differentiating Dizziness from Vertigo

Key Diagnostic Framework

The American Academy of Otolaryngology-Head and Neck Surgery recommends using a timing and triggers approach rather than focusing on symptom quality 2, 1:

1. Timing categories:

   • Acute vestibular syndrome (continuous dizziness lasting days to weeks)
   • Triggered episodic vestibular syndrome (brief episodes triggered by specific actions)
   • Spontaneous episodic vestibular syndrome (untriggered episodes lasting minutes to hours)
   • Chronic vestibular syndrome (dizziness lasting weeks to months)

2. Clinical presentation differences:

Feature	Vertigo	Dizziness (Non-vertiginous)
Sensation	Rotational or spinning	Lightheadedness, floating, imbalance
Duration	Usually brief (seconds to minutes) for BPPV; hours to days for other causes	Variable
Triggers	Often positional changes (BPPV)	Often standing, exertion, medications
Nystagmus	Present with peripheral causes	Usually absent
Associated symptoms	May have hearing loss, tinnitus (Ménière's)	May have palpitations, visual changes

Diagnostic Approach

Initial Assessment

1. For suspected vertigo:

   • Dix-Hallpike maneuver (gold standard for posterior canal BPPV): Position patient from sitting to supine with head turned 45° to one side and neck extended 20° 1
   • Supine roll test if Dix-Hallpike negative (for horizontal canal BPPV) 1
   • HINTS examination (Head Impulse, Nystagmus, Test of Skew) to differentiate peripheral from central causes 1

2. For suspected non-vertiginous dizziness:

   • Orthostatic vital signs
   • Cardiovascular assessment
   • Medication review
   • Neurological examination

Differential Diagnosis by Category

Triggered Episodic Vestibular Syndrome (Positional Vertigo)

• BPPV: Brief vertigo with position changes, positive Dix-Hallpike test 2, 1
• Central paroxysmal positional vertigo: Similar to BPPV but with atypical nystagmus 2
• Superior canal dehiscence syndrome: Vertigo triggered by sound or pressure 2

Acute Vestibular Syndrome

• Vestibular neuritis/labyrinthitis: Sudden severe vertigo lasting days with unidirectional nystagmus 2, 1
• Posterior circulation stroke: Vertigo with abnormal HINTS exam 1

Spontaneous Episodic Vestibular Syndrome

• Ménière's disease: Episodes with hearing loss, tinnitus, aural fullness 1
• Vestibular migraine: Variable duration, history of migraine, photophobia 1, 3
• TIA: Sudden onset with neurological deficits 1

Non-vertiginous Dizziness

• Postural hypotension: Lightheadedness upon standing 2
• Medication side effects: Various presentations 1
• Anxiety or panic disorder: Often chronic 2, 1

Management Strategies

For Vertigo

1. BPPV treatment:

   • Canalith Repositioning Procedure (Epley maneuver): First-line treatment with 80% success rate 1
   • Typically requires 1-3 treatments 1
   • Avoid vestibular suppressants for routine BPPV 1

2. Vestibular neuritis:

   • Early corticosteroid therapy to improve recovery 1
   • Vestibular rehabilitation for persistent symptoms 1

3. Ménière's disease:

   • Low-salt diet and diuretics
   • Audiogram for evaluation of hearing loss 1

4. Vestibular migraine:

   • Migraine prophylaxis
   • Trigger avoidance 3

5. Medication for acute symptoms:

   • Meclizine: 25-100 mg daily in divided doses for vertigo associated with vestibular system diseases 4
   • Caution: May cause drowsiness and has anticholinergic effects; use with care in patients with asthma, glaucoma, or prostate enlargement 1, 4

For Non-vertiginous Dizziness

1. Orthostatic hypotension:

   • Hydration
   • Gradual position changes
   • Compression stockings
   • Medication adjustment

2. Anxiety-related dizziness:

   • Cognitive behavioral therapy
   • Anxiolytics if appropriate

3. Medication-induced dizziness:

   • Medication review and adjustment

When to Consider Imaging

• Do not obtain radiographic imaging in patients meeting diagnostic criteria for BPPV without additional concerning symptoms 1
• Do obtain MRI brain (without contrast) for:
  • Acute Vestibular Syndrome with abnormal HINTS examination
  • Neurological deficits
  • High vascular risk patients with Acute Vestibular Syndrome
  • Chronic undiagnosed dizziness not responding to treatment 1

Follow-up and Monitoring

• Reassess within 1 month after initial treatment 1
• Educate about potential recurrence (15% per year for BPPV) 1
• Use validated assessment tools to track progress:
  • Activities-Specific Balance Confidence Scale
  • Dizziness Handicap Inventory
  • Dynamic Gait Index
  • Timed Up & Go test 1

Common Pitfalls to Avoid

• Focusing on symptom quality rather than timing and triggers 1, 5
• Failing to perform the Dix-Hallpike maneuver in patients with positional vertigo 1
• Routinely prescribing vestibular suppressants for BPPV 1
• Missing central causes of vertigo by not performing the HINTS examination 1
• Ordering unnecessary imaging in clear peripheral vertigo cases 1
• Overlooking stroke as a cause of isolated vertigo (HINTS is more sensitive than early MRI) 1