What is the recommended approach for evaluating giddiness?

Recommended Approach for Evaluating Giddiness

The recommended approach for evaluating giddiness should focus on characterizing the timing, triggers, and associated symptoms to classify it into one of four distinct vestibular syndromes, which will guide further evaluation and management. 1

Initial Classification of Giddiness

• Determine if the patient is experiencing true vertigo (sensation of rotation or spinning) versus non-specific dizziness (sensation of disturbed spatial orientation without false sense of motion) 1, 2
• Classify the dizziness into one of four categories based on timing and triggers 1, 3:
  • Acute vestibular syndrome (continuous dizziness lasting days to weeks)
  • Triggered episodic vestibular syndrome (brief episodes triggered by specific movements)
  • Spontaneous episodic vestibular syndrome (recurrent attacks without clear triggers)
  • Chronic vestibular syndrome (persistent dizziness lasting months to years)

Focused History

• Determine the duration of each episode: brief episodes (seconds) suggest BPPV, while longer episodes (minutes to hours) suggest Ménière's disease or vestibular migraine 1, 4
• Identify triggers such as positional changes (suggesting BPPV) or specific situations 1, 5
• Document associated symptoms 6:
  • Hearing loss, tinnitus, or aural fullness may suggest Ménière's disease
  • Headache, photophobia, or motion intolerance may suggest vestibular migraine
  • Neurological symptoms may indicate central causes requiring urgent evaluation

Physical Examination

• Perform a complete neurological examination to assess for focal deficits 3, 2
• Conduct the HINTS examination (Head-Impulse, Nystagmus, Test of Skew) to distinguish between peripheral and central causes of vertigo 3, 2
• Perform the Dix-Hallpike maneuver to evaluate for BPPV 6, 3
• Assess for nystagmus, noting the direction, duration, and triggers 6, 3

Diagnostic Testing

• Laboratory testing should be ordered selectively based on clinical suspicion 1, 7:
  • Basic metabolic panel, CBC, and thyroid function tests if dehydration, electrolyte abnormalities, infection, or thyroid disorder is suspected
• Imaging studies are generally not required in the initial workup unless red flags are present 6:
  • Do not order vestibular testing in a patient who meets diagnostic criteria for BPPV in the absence of additional vestibular signs/symptoms inconsistent with BPPV 6
  • Do not order neuroimaging in a patient who meets diagnostic criteria for BPPV in the absence of additional neurologic signs/symptoms 6
  • Consider MRI with diffusion-weighted imaging for patients with acute persistent vertigo with neurological deficits, HINTS examination suggesting central pathology, or risk factors for stroke 6

Common Diagnoses to Consider

• Benign Paroxysmal Positional Vertigo (BPPV): brief episodes triggered by head movement 6, 4
• Vestibular Migraine: vertigo with history of migraine, photophobia, or phonophobia 6, 3
• Ménière's Disease: vertigo with unilateral hearing loss, tinnitus, and aural fullness 1, 4
• Vestibular Neuritis/Labyrinthitis: acute onset vertigo lasting days 4, 2
• Central causes (stroke, TIA): often accompanied by other neurological symptoms 6, 3

Initial Management

• For BPPV: Perform canalith repositioning procedures (e.g., Epley maneuver) 3, 2
• For Ménière's disease: Recommend dietary modifications (sodium restriction, avoiding caffeine/alcohol/nicotine) 3
• For vestibular migraine: Consider migraine prophylaxis and lifestyle modifications 6
• For symptomatic relief of vertigo: Meclizine 25-100 mg daily in divided doses may be used short-term 8
  • Use with caution due to potential drowsiness and anticholinergic effects 8

Red Flags and Common Pitfalls

• Red flags requiring urgent evaluation include 1, 3:
  • Focal neurological deficits
  • Sudden hearing loss
  • Inability to stand or walk
  • New-onset severe headache
• Common pitfalls to avoid 1, 3:
  • Relying solely on the patient's description of "dizziness" without clarifying the exact nature of symptoms
  • Failing to perform the Dix-Hallpike maneuver in patients with positional symptoms
  • Over-reliance on vestibular suppressant medications, which may delay central compensation
  • Not recognizing that 25-50% of patients with recurrent BPPV may have associated vestibular pathology requiring additional evaluation