Initial Approach to a Patient Presenting with Dizziness
The initial workup for a patient with dizziness should focus on characterizing the symptoms by timing, triggers, and associated features rather than relying solely on the patient's subjective description of "dizziness." 1, 2, 3
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
- Categorize dizziness into one of four vestibular syndromes 3:
- Acute Vestibular Syndrome (persistent 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)
Key History Elements
- Duration of episodes: seconds (suggesting BPPV) versus minutes to hours (suggesting Ménière's disease or vestibular migraine) 2
- Triggers: positional changes (suggesting BPPV), pressure changes (suggesting superior canal dehiscence) 1
- Associated symptoms 2, 3:
- Hearing loss, tinnitus, aural fullness (suggesting Ménière's disease)
- Headache, photophobia (suggesting vestibular migraine)
- Neurological symptoms (suggesting central causes)
Physical Examination
- Perform a thorough otologic examination 1
- Observe for spontaneous nystagmus 3
- Conduct vestibular assessment 1:
- Dix-Hallpike maneuver (to diagnose posterior canal BPPV)
- Supine roll test (to diagnose horizontal canal BPPV)
- Perform neurological examination to assess for central causes 4
Diagnostic Testing
- Audiologic examination for patients with unilateral tinnitus, persistent symptoms, or hearing difficulties 1
- Laboratory testing (basic metabolic panel, CBC, thyroid function) if metabolic causes are suspected 2
- Neuroimaging (preferably MRI) only for patients with 1, 3:
- Unilateral tinnitus
- Focal neurological abnormalities
- Asymmetric hearing loss
- Atypical presentation or red flags
Common Diagnoses and Management
- Benign Paroxysmal Positional Vertigo (BPPV) 4:
- Diagnosed when vertigo with nystagmus is provoked by the Dix-Hallpike maneuver
- Treat with canalith repositioning procedures (e.g., Epley maneuver)
- Vestibular Neuritis/Labyrinthitis 2:
- Sudden severe vertigo with or without hearing loss
- Symptoms typically last 12-36 hours with decreasing disequilibrium over days
- Ménière's Disease 4:
- Episodic vertigo with fluctuating hearing loss, tinnitus, aural fullness
- Manage with salt restriction, diuretics, and sometimes intratympanic treatments
- Vestibular Migraine 1, 2:
- Attacks lasting hours (can be minutes to >24 hours)
- Associated with headache history and photophobia
Red Flags Requiring Urgent Evaluation
- Focal neurological deficits 1, 3
- Sudden hearing loss 1
- Inability to stand or walk 1
- Downbeating nystagmus or other central nystagmus patterns 1
- Failure to respond to appropriate vestibular treatments 1
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 (Dix-Hallpike maneuver and supine roll test) 1, 3
- Ordering unnecessary imaging studies in patients with clear peripheral causes of dizziness 1, 3
- Assuming absence of focal neurologic deficits rules out central causes 1
- Routinely treating BPPV with vestibular suppressant medications such as antihistamines or benzodiazepines 4