What is the initial workup for dizziness in an adolescent?

Initial Workup for Dizziness in an Adolescent

The initial workup for dizziness in an adolescent should focus on characterizing the type of dizziness through detailed history, physical examination, and targeted diagnostic testing based on the suspected etiology. 1

History Taking

• Determine the exact nature of the "dizziness" by clarifying whether it is true vertigo (sensation of rotation or spinning) versus non-specific dizziness (disturbed spatial orientation without false sense of motion) 1, 2
• Establish the timing and duration of episodes:
  • Brief episodes (seconds) suggest BPPV 1, 3
  • Longer episodes (minutes to hours) suggest Ménière's disease, vestibular migraine, or other conditions 1, 3
• Identify triggers for dizziness:
  • Positional changes may indicate BPPV or other peripheral vestibular disorders 1, 2
  • Exercise-induced dizziness may suggest cardiovascular causes 4
  • Relationship to menstruation in female adolescents may suggest vestibular migraine 5
• Document associated symptoms:
  • Headache and photophobia may suggest vestibular migraine 1, 5
  • Hearing loss, tinnitus, or aural fullness may suggest Ménière's disease 1, 3
  • Neurological symptoms require urgent evaluation 1, 5

Physical Examination

• Complete otologic examination including assessment of the tympanic membrane 1, 6
• Neurological examination focusing on cranial nerves, cerebellar function, and gait 5, 6
• Cardiovascular examination including orthostatic blood pressure measurement 5, 3
• Special tests:
  • Dix-Hallpike maneuver to assess for BPPV 1, 2, 3
  • Supine roll test for horizontal canal BPPV 1
  • HINTS examination (Head-Impulse, Nystagmus, Test of Skew) to distinguish peripheral from central causes of vertigo 5, 2
  • Assessment for spontaneous and gaze-evoked nystagmus 5, 6

Laboratory Testing

• Basic metabolic panel if dehydration or electrolyte abnormalities are suspected 1
• Complete blood count if infection is suspected 1
• Thyroid function tests if thyroid disorder is suspected 1
• Pregnancy test in female adolescents when appropriate 4

Imaging Studies

• Imaging is generally not required in the initial workup unless there are neurological symptoms, atypical presentation, or red flags 5, 1
• When imaging is indicated:
  • MRI head without contrast is the preferred modality for suspected central causes 5
  • CT head without contrast may be appropriate as initial imaging in emergency situations 5

Red Flags Requiring Urgent Evaluation

• Focal neurological deficits 1
• Sudden hearing loss 1
• Inability to stand or walk 1
• Abnormal HINTS examination suggesting central etiology 5
• Persistent symptoms despite appropriate treatment 5

Common Pitfalls to Avoid

• Relying solely on the patient's description of "dizziness" without clarifying the exact nature of symptoms 1, 4
• Failing to perform the Dix-Hallpike maneuver and supine roll test in patients with positional symptoms 1, 3
• Ordering unnecessary imaging studies in patients with typical peripheral vestibular disorders 5
• Overlooking medication side effects as a potential cause of dizziness 3
• Dismissing symptoms as psychogenic without adequate evaluation 4, 3