What is the approach to evaluating dizziness and vertigo?

From the Guidelines

Evaluating dizziness and vertigo begins with distinguishing between the two sensations: dizziness is a feeling of lightheadedness or unsteadiness, while vertigo specifically involves a false sensation of movement or spinning, as defined by the Barany Society 1.

Key Components of Evaluation

• A thorough history is essential, focusing on onset, duration, triggers, and associated symptoms like nausea, hearing changes, or neurological symptoms.
• Physical examination should include vital signs, particularly orthostatic measurements, along with neurological testing, ear examination, and specific maneuvers like the Dix-Hallpike test for benign paroxysmal positional vertigo (BPPV) 1.
• The HINTS exam (Head Impulse, Nystagmus, Test of Skew) can help differentiate peripheral from central causes, especially in patients with acute vestibular syndrome (AVS) 1.

Diagnostic Approach

• Laboratory tests may include complete blood count, metabolic panel, and thyroid function tests to rule out systemic causes.
• Imaging studies like MRI may be necessary if central nervous system pathology is suspected, particularly in cases with associated neurologic symptoms or signs unrelated to BPPV 1.

Treatment and Management

• Common treatments include vestibular rehabilitation exercises, medications such as meclizine 25mg every 4-6 hours for symptomatic relief, and specific interventions like the Epley maneuver for BPPV 1.
• For Ménière's disease, a low-salt diet and diuretics like hydrochlorothiazide 25mg daily may help, as suggested by clinical practice guidelines 1.
• Persistent or concerning symptoms warrant referral to specialists like neurologists or otolaryngologists for further evaluation and management.

Importance of Clinical Judgment

• The evaluation pathway is guided by understanding the vestibular system's role in maintaining balance through integration of visual, proprioceptive, and inner ear inputs, and clinical judgment plays a crucial role in diagnosing and managing dizziness and vertigo, as emphasized by recent clinical practice guidelines 1.

From the Research

Evaluation of Dizziness and Vertigo

To evaluate dizziness and vertigo, clinicians should focus on the timing of the events and triggers of dizziness to develop a differential diagnosis 2, 3, 4. The differential diagnosis is broad and includes peripheral and central causes.

• Peripheral etiologies can cause significant morbidity but are generally less concerning, whereas central etiologies are more urgent 2, 3.
• The physical examination may include:
  • Orthostatic blood pressure measurement
  • A full cardiac and neurologic examination
  • Assessment for nystagmus
  • The Dix-Hallpike maneuver (for patients with triggered dizziness)
  • The HINTS (head-impulse, nystagmus, test of skew) examination when indicated 2, 3.
• Laboratory testing and imaging are usually not required but can be helpful 2, 3.

Approach to Evaluation

A timing-and-triggers approach should be used to first characterize the patient's vestibular symptoms as continuous or episodic 4.

• If acute and continuous, determine whether symptoms are post-exposure or spontaneous.
• If episodic, determine whether symptoms are triggered or spontaneous.
• Classify the patient as having post-exposure acute vestibular syndrome (AVS), spontaneous AVS, triggered episodic vestibular syndrome (EVS), or spontaneous EVS 4.

Treatment Options

The treatment for dizziness is dependent on the etiology of the symptoms 2, 3.

• Canalith repositioning procedures (e.g., Epley maneuver) are the most helpful in treating benign paroxysmal positional vertigo.
• Vestibular rehabilitation is helpful in treating many peripheral and central etiologies.
• Other etiologies of dizziness require specific treatment to address the cause.
• Pharmacologic intervention is limited because it often affects the ability of the central nervous system to compensate for dizziness 2.