What is the recommended approach for evaluating dizziness?

Recommended Approach for Evaluating Dizziness

The evaluation of dizziness should follow a structured approach focusing on timing, triggers, and associated symptoms, with specific diagnostic maneuvers like the Dix-Hallpike test for vertigo and the HINTS examination when indicated. 1

Initial Classification of Dizziness

Dizziness should be categorized into one of four types based on the patient's description:

1. Vertigo: Sensation of rotation or spinning

   • Brief duration (seconds to minutes) for BPPV; hours to days for other causes
   • Often triggered by positional changes
   • May present with nystagmus
   • May have associated hearing loss or tinnitus (e.g., Ménière's disease)

2. Disequilibrium: Feeling of imbalance without spinning

   • Consider neurological causes like Parkinson's disease or diabetic neuropathy

3. Presyncope: Near-fainting sensation

   • Often related to orthostatic hypotension or medication effects
   • Check for blood pressure drop (≥20 mmHg systolic or ≥10 mmHg diastolic within 3 minutes of standing)

4. Lightheadedness: Vague sensation of disconnection

   • May be related to psychiatric disorders, anxiety, or hyperventilation

Key Diagnostic Maneuvers

For Vertigo Evaluation:

• Dix-Hallpike Maneuver: Essential for diagnosing BPPV

  • Positive test shows nystagmus with characteristic latency and limited duration
  • Failure to perform this test in patients with positional vertigo is a common pitfall 1

• HINTS Examination: For acute vestibular syndrome

  • Head-Impulse test
  • Nystagmus evaluation
  • Test of Skew
  • Abnormal results warrant immediate neuroimaging to rule out stroke 1

For Orthostatic Hypotension:

• Measure blood pressure and heart rate supine, then after standing for 3 minutes
• Diagnostic drop: ≥20 mmHg systolic or ≥10 mmHg diastolic 1

Imaging Recommendations

Imaging is not routinely indicated for isolated vertigo without focal neurological deficits. However, CT scans of the head should be performed when vertigo is accompanied by:

• Severe headache
• Age >60 years
• Vomiting
• Drug/alcohol intoxication
• Short-term memory deficits
• Trauma above the clavicle
• Seizures
• Focal neurological deficits 1

MRI brain (without contrast) is indicated for:

• Acute Vestibular Syndrome with abnormal HINTS examination
• Acute Vestibular Syndrome with neurological deficits
• High vascular risk patients with Acute Vestibular Syndrome even with normal examination
• Chronic undiagnosed dizziness not responding to treatment 1

Treatment Approaches Based on Diagnosis

1. For BPPV:

   • Canalith Repositioning Procedure (Epley maneuver) - 80% success rate 1
   • Avoid routine prescription of vestibular suppressants 1

2. For Acute Vestibular Syndrome:

   • Early corticosteroid therapy if peripheral cause confirmed
   • Rule out stroke with HINTS examination 1

3. For Orthostatic Hypotension:

   • Medication adjustment
   • Hydration
   • Compression stockings
   • Gradual position changes 1
   • Consider alpha agonists or mineralocorticoids in persistent cases 2

4. For Persistent Dizziness:

   • Vestibular rehabilitation (can be self-administered or clinician-directed) 1

Common Pitfalls to Avoid

1. Focusing on the quality of dizziness rather than timing and triggers 1
2. Failing to perform the Dix-Hallpike maneuver in patients with positional vertigo 1
3. Routinely prescribing vestibular suppressants for BPPV 1
4. Missing central causes of vertigo by not performing the HINTS examination 1
5. Ordering unnecessary imaging studies in patients with clear peripheral vertigo 1
6. Overlooking medication side effects as a cause of dizziness 2
7. Rapid withdrawal of corticosteroids like fludrocortisone, which may cause adverse reactions 3

Special Considerations

• Medication Review: Many medications can cause dizziness, particularly those affecting blood pressure

  • Fludrocortisone and other corticosteroids require careful monitoring for side effects including dizziness 3
  • Patients on corticosteroids should be monitored regularly for blood pressure and serum electrolytes 3

• Validated Assessment Tools:

  • Activities-Specific Balance Confidence Scale
  • Dizziness Handicap Inventory
  • Dynamic Gait Index
  • Timed Up & Go test 1

• Commercial Drivers: Require comprehensive evaluation due to public safety concerns 1

The evaluation of dizziness should be systematic and thorough, as approximately 20% of cases may remain undiagnosed despite evaluation 4. Laboratory testing and radiography play a limited role in diagnosis for most cases 2, and treatment should be directed at the specific underlying cause.