What is the best course of action for a 55-year-old female patient with symptoms of nausea, cough, and dizziness, and a history of dizziness?

Management of a 55-Year-Old Female with Nausea, Cough, and Dizziness

Begin by clarifying the nature of the dizziness through specific questioning—ask "Do you feel like you or the room is spinning?" to distinguish true vertigo from other forms of dizziness, as this fundamentally changes your diagnostic approach and determines whether you're dealing with vestibular pathology versus cardiovascular, metabolic, or other causes. 1

Initial Diagnostic Approach

Characterize the Dizziness First

The most critical first step is determining which of four categories this patient's dizziness falls into, as timing and triggers are more reliable than patient descriptors 2, 3:

• True vertigo (spinning sensation) indicates vestibular system pathology 1
• Presyncope (lightheadedness, near-fainting) suggests cardiovascular or medication causes 4, 3
• Disequilibrium (imbalance without spinning) points to neurologic causes like Parkinson's or diabetic neuropathy 4
• Non-specific lightheadedness often relates to psychiatric disorders (depression, anxiety, hyperventilation) 4

Key questions to ask 5, 1:

• Duration of spinning episodes (seconds, minutes, hours, or entire day)
• Onset pattern (spontaneous or provoked by head position)
• Concurrent symptoms during attacks (hearing changes, tinnitus, ear fullness)
• Triggers (head position changes, light sensitivity, motion intolerance)
• Any loss of consciousness (if yes, this is NEVER vestibular—consider cardiac/neurologic causes) 5, 1

Address the Cough Component

For the cough, your initial history must determine the duration to guide management 5:

• Acute cough (<3 weeks): First exclude life-threatening causes (pneumonia, pulmonary embolism), then consider common cold, acute bronchitis, or environmental exposures 5
• Subacute cough (3-8 weeks): Determine if postinfectious versus other causes 5
• Chronic cough (>8 weeks): Systematically evaluate for the most common causes—upper airway cough syndrome (UACS), asthma, non-asthmatic eosinophilic bronchitis (NAEB), and GERD 5

Critical history elements for cough 5:

• ACE inhibitor use (stop the medication if present) 5
• Smoking status (most common cause of persistent cough) 5
• Associated throat clearing or post-nasal drip sensation 5
• Timing (worse at night/after meals suggests GERD; nocturnal cough can indicate asthma, infection, or heart failure) 5

Consider the Nausea in Context

The combination of nausea with dizziness and cough raises several possibilities:

• If true vertigo is present, nausea is an expected vestibular symptom 5
• If cough is chronic, consider GERD as a unifying diagnosis causing both cough and nausea 5, 6
• GERD can present with nausea even without typical heartburn (up to 75% of GERD patients lack typical GI symptoms) 6

Physical Examination Priorities

Perform these specific bedside tests 2, 3:

• Orthostatic blood pressure measurement (to identify presyncope from orthostatic hypotension) 2, 3
• Assessment for nystagmus (indicates vestibular pathology) 2, 3
• Dix-Hallpike maneuver (if triggered episodic dizziness to diagnose benign paroxysmal positional vertigo) 2, 3
• Full cardiac and neurologic examination 2, 3

Differential Diagnosis Based on Dizziness Pattern

If Episodic Vertigo Triggered by Head Position

Most likely benign paroxysmal positional vertigo (BPPV) 3:

• Treat with Epley maneuver (canalith repositioning procedure) 4, 3
• Consider vestibular rehabilitation 2

If Episodic Vertigo with Hearing Changes

Consider Ménière's disease or vestibular migraine 5:

• Ménière's: Fluctuating hearing loss, tinnitus, aural fullness with vertigo episodes lasting 20 minutes to hours 5
• Vestibular migraine: May have short (<15 min) or prolonged (>24 hours) vertigo, light sensitivity, motion intolerance, minimal/stable hearing loss 5
• Inquire about migraine history (current or past headaches, visual auras, photophobia) 5

If Presyncope Pattern

Evaluate medications and cardiovascular causes 4:

• Review all medications (many cause presyncope) 4
• Treat orthostatic hypotension with alpha agonists, mineralocorticoids, or lifestyle changes 4

Management of Concurrent Cough

If chronic cough is present, use sequential and additive empiric therapy 5:

1. Start with first-generation antihistamine/decongestant for UACS 5
2. If inadequate response, add or switch to asthma treatment (inhaled corticosteroids, bronchodilators) 5
3. If still inadequate, treat for GERD 5, 6:
   • Implement lifestyle modifications (avoid eating 2-3 hours before bed, elevate head of bed, avoid trigger foods, weight loss if overweight, smoking cessation) 6
   • Start PPI therapy once daily for 4-8 weeks 6
   • If partial response, increase to twice-daily PPI 6
   • Consider adding prokinetic agent (metoclopramide) if minimal response 6

Important caveat: More than one cause of cough may be present simultaneously, requiring additive therapy 5

Critical Pitfalls to Avoid

• Do not assume dizziness quality from patient description alone—patients have difficulty accurately describing symptoms; focus on timing and triggers instead 1, 2, 3
• Do not overlook vestibular migraine—it commonly mimics Ménière's disease and requires different management 5
• Do not order routine imaging or labs for dizziness—they are usually not helpful and not required 2, 3
• Do not treat cough symptomatically without addressing underlying causes—chronic cough requires systematic evaluation of UACS, asthma, NAEB, and GERD 5
• If prescribing metoclopramide for GERD-related nausea, be aware of serious risks including tardive dyskinesia (especially with use >12 weeks), neuroleptic malignant syndrome, and acute dystonic reactions (more common in women <30 years old) 7

When to Refer or Escalate

• If complete workup and therapeutic trials fail to identify cause of chronic cough, consider referral to cough specialist 5
• If acute vestibular syndrome with concerning central features, urgent neurologic evaluation is needed 2, 3
• About 20% of dizziness cases remain undiagnosed despite thorough evaluation 4