From the Guidelines
The workup for dizziness should begin with a careful history to distinguish between vertigo, lightheadedness, disequilibrium, or presyncope, and then proceed with vital signs, a focused neurological examination including the HINTS exam, and laboratory tests as guided by the initial assessment. The evaluation of dizziness is complex due to its multifactorial nature, involving potential vestibular, cardiovascular, neurological, metabolic, or medication-related causes.
Initial Evaluation
- Start with vital signs including orthostatic measurements.
- Perform a focused neurological examination including the HINTS exam (Head Impulse, Nystagmus, Test of Skew) for suspected vertigo, as recommended by 1.
- Laboratory tests should include complete blood count, basic metabolic panel, thyroid function, and HbA1c.
Specific Considerations
- For persistent vertigo, the Dix-Hallpike maneuver can help diagnose benign paroxysmal positional vertigo (BPPV), as discussed in 1.
- Imaging studies like MRI brain with attention to the posterior fossa should be considered for patients with neurological symptoms, new-onset vertigo, or risk factors for stroke, based on the guidelines from 1.
- Audiometry may be appropriate for patients with hearing changes or tinnitus.
- For recurrent unexplained dizziness, consider 24-hour Holter monitoring, tilt-table testing, or vestibular function tests, as suggested by 1 and 1.
Imaging and Further Testing
The decision to proceed with imaging or further testing should be guided by the clinical presentation and the results of the initial evaluation. For patients with nonspecific dizziness without vertigo, ataxia, or other neurologic deficits, the diagnostic yield of CT and MRI is low, as noted in 1. However, in cases where there are neurological symptoms or risk factors for stroke, imaging may be crucial for diagnosis, as indicated by 1.
Conclusion of Approach
Given the complexity and the potential for serious underlying conditions, a systematic and stepwise approach to the evaluation of dizziness is necessary. This approach should prioritize the patient's history, physical examination, and selectively use laboratory and imaging tests to guide diagnosis and management, always considering the most recent and highest quality evidence, such as that provided by 1 and 1.
From the Research
Dizziness Workup
- The approach to evaluating dizziness involves characterizing the patient's symptoms as continuous or episodic, and determining whether they are triggered or spontaneous 2
- The timing and triggers of dizziness are crucial in developing a differential diagnosis, as patients often have difficulty describing the quality of their symptoms 3, 4
- The physical examination should include:
- Laboratory testing and imaging are usually not required, but can be helpful in certain cases 3, 4
Common Causes of Dizziness
- Benign paroxysmal positional vertigo (BPPV) can be diagnosed from associated positional torsional or direction-changing horizontal nystagmus, and can be treated with canalith repositioning procedures 3, 5
- Vestibular neuritis and other acute peripheral vestibulopathies can be diagnosed from associated unidirectional horizontal nystagmus 5
- Meniere disease can be suspected in patients with vertigo and unilateral hearing loss, and can be treated with salt restriction and diuretics 3
- Central etiologies, such as brainstem or cerebellar disorders, can cause vertigo or dizziness, and often require urgent treatment 3, 5
Treatment Options
- Canalith repositioning procedures (e.g., Epley maneuver) are effective in treating BPPV 3, 6, 4
- Vestibular rehabilitation is helpful in treating many peripheral and central etiologies of dizziness 3, 4
- Pharmacologic intervention is limited, as it can affect the ability of the central nervous system to compensate for dizziness 4