From the Guidelines
Dizziness diagnostic workup should start with a thorough history and physical examination to identify the underlying cause, with imaging and further testing only considered if atypical features or red flags are present.
Key Components of Diagnostic Workup
- A detailed history of symptoms, including nature, onset, duration, and concurrent otologic symptoms
- Physical examination, including assessment of vestibular function and neurologic evaluation
- Use of specific maneuvers, such as the Dix-Hallpike test, to diagnose benign paroxysmal positional vertigo (BPPV) 1
- Consideration of other potential causes of vertigo, including Meniere's disease, vestibular migraine, and central causes 1
Imaging and Further Testing
- Imaging, such as MRI, is not required for diagnosis of BPPV or vestibular migraine, but may be considered if atypical features or red flags are present 1
- Vestibular testing, such as electronystagmography, may be considered if diagnosis is uncertain or if patient has persistent symptoms 1
- Audiogram and other hearing tests may be considered if patient has symptoms of hearing loss or tinnitus 1
Important Considerations
- Clinicians should differentiate between BPPV and other causes of imbalance, dizziness, and vertigo 1
- Patients with atypical features or red flags, such as lack of nystagmus on provoking maneuvers or lack of response to treatment maneuvers, may require further evaluation and imaging 1
- A confident description of spinning is typically specific for inner ear dysfunction and Meniere's disease, and clinicians should ask patients detailed questions about their symptoms to establish a reliable diagnosis 1
From the Research
Diagnostic Approach
The diagnostic workup for dizziness involves a focused approach to differentiate between benign and serious conditions. According to 2, 3, 4, 5, the traditional approach of categorizing dizziness based on symptom quality or type (vertigo, presyncope, disequilibrium) is outdated and inconsistent with current best evidence.
Key Categories
Patients with dizziness can be divided into three key categories based on timing and triggers:
- Acute vestibular syndrome: where bedside physical examination differentiates vestibular neuritis from stroke 2, 5
- Spontaneous episodic vestibular syndrome: where associated symptoms help differentiate vestibular migraine from transient ischemic attack 2, 5
- Triggered episodic vestibular syndrome: where the Dix-Hallpike and supine roll test help differentiate benign paroxysmal positional vertigo from posterior fossa structural lesions 2, 3, 5
Physical Examination
The physical examination may include:
- Orthostatic blood pressure measurement 3, 6
- Full cardiac and neurologic examination 3
- Assessment for nystagmus 3, 6
- Dix-Hallpike maneuver (for patients with triggered dizziness) 2, 3, 5, 6
- HINTS (head-impulse, nystagmus, test of skew) examination when indicated 3
Laboratory Testing and Imaging
Laboratory testing and imaging are usually not required but can be helpful in certain cases 3, 6. A final diagnosis is not obtained in about 20 percent of cases 6.
Treatment
Treatment for dizziness is dependent on the etiology of the symptoms. Canalith repositioning procedures (e.g., Epley maneuver) are helpful in treating benign paroxysmal positional vertigo 3, 6. Vestibular rehabilitation is helpful in treating many peripheral and central etiologies 3. Other etiologies of dizziness require specific treatment to address the cause 3, 6.