From the Guidelines
The workup for vertigo (dizziness) should begin with a detailed history and physical examination to distinguish between vertigo, presyncope, disequilibrium, and non-specific dizziness, and may include the Dix-Hallpike maneuver to diagnose benign paroxysmal positional vertigo (BPPV) as recommended by the clinical practice guideline: benign paroxysmal positional vertigo (update) executive summary 1.
Initial Evaluation
The initial evaluation should include:
- Vital signs (blood pressure, heart rate, orthostatic measurements)
- Neurological examination
- Otoscopic examination
Laboratory Tests
Laboratory tests should include:
- Complete blood count
- Basic metabolic panel
- Thyroid function tests
- Vitamin B12 levels to identify anemia, electrolyte abnormalities, or metabolic disorders
Additional Testing
Additional testing may include:
- Audiometry
- Videonystagmography
- Vestibular evoked myogenic potentials for inner ear disorders
- Brain imaging (CT or MRI) is indicated when central nervous system pathology is suspected, particularly with focal neurological deficits, new-onset severe headache, or risk factors for stroke
- Carotid ultrasound may be appropriate for patients with vascular risk factors
- For recurrent unexplained dizziness, ambulatory cardiac monitoring (Holter or event monitor) can detect intermittent arrhythmias
Diagnosis of BPPV
The diagnosis of BPPV can be made using the Dix-Hallpike maneuver, which is a strong recommendation according to the clinical practice guideline: benign paroxysmal positional vertigo (update) executive summary 1.
Importance of Accurate Diagnosis
It is essential to accurately diagnose the underlying cause of dizziness, as management strategies differ significantly depending on whether the etiology is peripheral vestibular, central, cardiovascular, or metabolic in nature, and to improve patient outcomes in terms of morbidity, mortality, and quality of life 1.
From the Research
Workup for Vertigo (Dizziness)
The workup for vertigo, or dizziness, involves a thorough history and physical examination to determine the underlying cause of the symptoms. The differential diagnosis is broad and includes peripheral and central causes 2, 3.
- Peripheral etiologies can cause significant morbidity but are generally less concerning, whereas central etiologies are more urgent 2.
- The physical examination may include:
- Laboratory testing and imaging are usually not required but can be helpful in certain cases 2, 3, 4.
Diagnostic Approach
The most useful diagnostic approach is a thorough history and physical examination, with additional tests rarely necessary 4.
- Patients have difficulty describing the quality of their symptoms but can more consistently identify the timing and triggers 2, 3.
- Episodic vertigo triggered by head motion may be due to benign paroxysmal positional vertigo, while vertigo with unilateral hearing loss suggests Meniere disease 3.
- The HINTS examination can help distinguish peripheral from central etiologies 2, 3.
Treatment
Treatment for dizziness is dependent on the etiology of the symptoms 2.
- Canalith repositioning procedures (e.g., Epley maneuver) are the most helpful in treating benign paroxysmal positional vertigo 2, 3.
- Vestibular rehabilitation is helpful in treating many peripheral and central etiologies 2, 3.
- Pharmacologic intervention is limited because it often affects the ability of the central nervous system to compensate for dizziness 2, 5.