What is the approach to evaluating and managing chronic dizziness?

Evaluation and Management of Chronic Dizziness

The most effective approach to evaluating chronic dizziness is to classify it based on timing, triggers, and associated symptoms to determine the appropriate diagnostic pathway and management strategy. 1, 2

Initial Classification of Dizziness

• Determine if the patient is experiencing true vertigo (sensation of rotation or spinning) versus non-specific dizziness (disturbed spatial orientation without false sense of motion) 1, 2
• Classify dizziness into one of four categories to guide further evaluation:
  • 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 or longer) 1, 2

Focused History for Chronic Dizziness

• Document precise timing and duration of episodes 2, 3
• Identify specific triggers such as positional changes (suggesting BPPV) or pressure changes (suggesting superior canal dehiscence or perilymph fistula) 1, 2
• Assess for associated symptoms:
  • Hearing loss, tinnitus, or aural fullness (suggesting Ménière's disease) 1
  • Headache, photophobia, or motion sensitivity (suggesting vestibular migraine) 2
  • Neurological symptoms (suggesting central causes) 1, 4
• Review medication history as many medications can cause dizziness 5
• Evaluate for history of trauma, recent infections, or cardiovascular risk factors 1

Physical Examination

• Perform a thorough otologic examination 1
• Conduct vestibular assessment:
  • Dix-Hallpike maneuver for patients with positional triggers (to evaluate for BPPV) 1, 2
  • Supine roll test for horizontal canal BPPV 2
  • Assess for nystagmus patterns (direction, duration, and triggers) 1, 4
• Complete neurological examination including cerebellar testing 1, 4
• Measure orthostatic blood pressure if presyncope is suspected 5, 6
• Perform HINTS examination (Head-Impulse, Nystagmus, Test of Skew) if central causes are suspected 4

Diagnostic Testing

• Obtain comprehensive audiologic examination for patients with:
  • Unilateral tinnitus
  • Persistent symptoms (≥6 months)
  • Associated hearing difficulties 1
• Consider neuroimaging (preferably MRI) only for patients with:
  • Unilateral tinnitus
  • Pulsatile tinnitus
  • Focal neurological abnormalities
  • Asymmetric hearing loss
  • Atypical presentation or red flags 1
• Laboratory testing is generally low-yield unless specific conditions are suspected:
  • Basic metabolic panel for electrolyte abnormalities
  • Thyroid function tests if thyroid disorder is suspected 2, 7

Common Diagnoses and Management

• Benign Paroxysmal Positional Vertigo (BPPV):

  • Diagnosed with positive Dix-Hallpike or supine roll test
  • Treat with canalith repositioning procedures (e.g., Epley maneuver) 1, 6
  • Reassess treatment failures for persistent BPPV or alternative diagnoses 1

• Ménière's Disease:

  • Characterized by episodic vertigo with fluctuating hearing loss, tinnitus, and aural fullness
  • Management includes salt restriction, diuretics, and in some cases, intratympanic treatments 1, 6

• Vestibular Migraine:

  • Presents with episodic vertigo associated with migrainous features
  • Treat with migraine prophylaxis and lifestyle modifications 1, 8

• Persistent Postural-Perceptual Dizziness:

  • Chronic dizziness following an initial vestibular insult
  • Management includes vestibular rehabilitation and sometimes selective serotonin reuptake inhibitors 8

• Central Causes (including cerebrovascular disease):

  • Requires prompt neurological evaluation and appropriate imaging
  • Management depends on specific etiology 1, 4

Red Flags Requiring Urgent Evaluation

• Focal neurological deficits 4
• Sudden hearing loss 1
• Inability to stand or walk 2
• Failure to respond to appropriate vestibular treatments 4
• Downbeating nystagmus or other central nystagmus patterns 4

Common Pitfalls to Avoid

• Relying solely on the patient's description of "dizziness" without clarifying the exact nature of symptoms 1, 3
• Failing to perform appropriate positional testing in patients with triggered symptoms 2
• Overreliance on CT imaging, which frequently misses posterior circulation strokes 4
• Assuming absence of focal neurologic deficits rules out central causes 4
• Treating symptoms without establishing a diagnosis 5