Dizziness: Evaluation and Management
SUMMARY:
Dizziness is a common chief complaint for primary care providers, accounting for up to 5% of primary care visits. Dizziness is often used as a catchall term by patients to describe a wide range of symptoms from vertigo and disequilibrium to presyncope and lightheadedness. Given this spectrum of symptomology, it can be difficult to diagnose the underling etiology if providers rely only on a patient’s reported symptoms. The American Academy of Family Physicians (AAFP) has created a guideline to assist with the evaluation and management of dizziness as an outpatient. Their recommendations highlight the importance of using a systematic approach when evaluating dizziness to reliably distinguish between central and peripheral etiologies and benign and serious causes.
- Definitions
- Evaluation
- Differential Diagnosis and Treatment
- Key Points
Definitions
- AAFP defines vertigo and dizziness as separate entities, though patients’ reports can be vague, and they may use these terms interchangeably
- Vertigo is a “sensation of distorted self-motion when no self-motion is occurring”
- Dizziness is a “sensation of disturbed of impaired spatial orientation without a false or distorted sense of motion”
Evaluation
- History taking and physical examination are crucial first steps in diagnosing dizziness, and can quickly help providers narrow down their differential diagnosis
- Patients’ descriptions of their symptoms have been found unreliable on their own for establishing the underlying etiology of dizziness and should always be used in conjunction with a physical exam
- Evaluate each patient with a consistent and systematic approach
- AAFP recommends the “TiTrATE” method: Timing of symptoms | Triggers that provoke the symptom | Targeted Examination
- Timing of symptoms: Onset | Duration | Evolution of dizziness
- Episodic vestibular syndromes: Transient symptoms of dizziness lasting seconds to hours
- Acute vestibular symptoms: Acute-onset AND continuous symptoms lasting days to weeks
- Triggered vs. Spontaneous
- Triggers that provoke symptoms include: Actions | Movements | Situations | Drugs | Trauma
- Medications and substances that can trigger dizziness include: Antiarrhythmics | Antihistamines | Antihypertensive | Narcotics | Parkinson disease drugs | Nitrates | Digoxin | Muscle relaxants | Alcohol | Anti-seizure medications | Lithium | Antidiabetic drugs | Aminoglycosides (due to ototoxicity) | Benzodiazepines | Urinary anticholinergics
- Targeted examination
- Physical Exam can include: Orthostatic blood pressure measurements | Nystagmus assessment | Dix-Hallpike maneuver | HINTS examination
- HINTS (e.g., Head-impulse | Nystagmus | Test of skew) exam is made up of three physical examination findings to help delineate between central and peripheral etiology of dizziness with high sensitivity (>95%)
- Patients with triggered episodic symptoms should be evaluated with: Dix-Hallpike | Orthostatic vitals
- Patients with spontaneous acute vestibular syndrome should be evaluated with HINTS exam, and if HINTS is normal (indicating central etiology), MRI w/ and w/o contrast should be obtained
- If central cause of spontaneous acute vestibular syndrome is suspected, then patients should undergo a full neurologic examination in an inpatient or emergency room setting
- Laboratory testing | Imaging
- In patients with dizziness and concomitant hearing loss or aural fullness consider imaging with CT of the temporal bone or MRI head and internal auditory canal
- If central cause of dizziness is suspected (e.g., Tumor | Stroke | Demyelination) consider obtaining MRI brain w/ and w/o contrast
- Further laboratory testing (e.g., Glucose | TSH | Vitamin levels) should not be routinely obtained outside of high clinical suspicion in the appropriate context
- Patients with cardiac disease symptoms and dizziness should have: EKG | Holter monitoring | 28-day event monitoring | +/- Carotid US
- Routine troponin testing in older patients is not recommended due to high false-positive rate
Differential Diagnosis and Treatment
- Peripheral etiologies are the most common causes of dizziness
- While less common as cause of dizziness, central etiologies include life threatening diagnoses and must be ruled out when assessing a patient
Peripheral Causes
- Benign paroxysmal positional vertigo (BPPV)
- Most common cause of peripheral dizziness, caused by loose canaliths stuck in the inner ear’s semicircular canals
- Triggered and episodic
- Can occur at any age but more common as patients get older (e.g., between the ages of 50 and 70), younger patients with BPPV more likely to have a preceding trauma
- Affects women more than men
- Diagnosed via Dix-Hallpike maneuver and treated with repositioning maneuvers (e.g., Epley maneuver)
- Vestibular rehab referral should be combined with repositioning maneuvers for best outcomes
- Pharmacologic treatments (e.g., Antihistamines | Benzodiazepines) should be avoided because they interfere with a patient’s ability to centrally compensate and can increase risk of falls
- Some studies have found a decreased risk of BPPV recurrence by repleting vitamin D in patients with vitamin D deficiency and BPPV
- Vestibular neuritis
- 2nd most common cause of peripheral dizziness
- Often due to a preceding viral infection and occurs most often in patients aged 30 to 50
- Associated with: Severe vertigo | Nausea | Nystagmus
- Symptoms generally resolve with supportive care after a few days with attacks lasting progressively shorter durations until they resolve completely
- Mainstay of treatment is reassurance coupled with symptomatic treatment and vestibular rehabilitation
- Steroids and antiviral agents are not affected and have no role in treatment
- Meniere Disease (MD)
- 3rd most common cause of peripheral dizziness
- Associated with: Tinnitus | Aural fullness | Hearing loss | Unidirectional horizontal nystagmus
- Biphasic age distribution commonly occurring in patients in their 20s and 60s
- Thought to be a result of excess endolymphatic fluid leading to inner ear dysfunction
- Audiogram should be obtained in all patients with suspected MD
- Though lacking strong evidence, treatment generally includes: Decreasing dietary sodium (< 2000 mg/day) | Reducing caffeine intake | Limiting alcohol (≤ 1 drink/day)
- While diuretics are often used in practice, evidence is insufficient to recommend this treatment
- Vestibular suppressants (e.g., Prochlorperazine (Compazine) | Benzodiazepines | Promethazine (Phenergan) may be used to control symptoms during acute attacks
- Labyrinthectomy can be considered for refractory symptoms
- Less common etiologies include: Acute coronary syndrome | Hypoglycemia | Anemia | Aortic dissection | Arrhythmia | Behavioral health concerns | Ectopic pregnancy | Hormonal imbalance | Infection | Metabolic disorders | Otosclerosis | Pulmonary embolus | Thyroid disease | Vasovagal reflex | Drug intoxication | Medications
Central Causes
- Vestibular migraine
- Most common type of spontaneous episodic vestibular syndrome
- More common in females and generally occurs in midlife (e.g., mean age of 40 years)
- Occur with a headache or headache history
- Diagnostic criteria includes: Recurrent (≥ 5 episodes) vestibular symptoms | Symptoms last anywhere from 5 minutes to 72 hours | Previous or current migraines
- If associated with hearing changes audiology evaluation should be obtained
- Treatment incudes: Lifestyle modifications if migraine triggers identified | Migraine abortive agents (e.g., Triptans) | Migraine preventative medications e.g., Topiramate (Topamax) | Amitriptyline (Elavil) | Propranolol (Inderal)
- Vertebrobasilar ischemia
- Nearly half of patients present with vertigo or dizziness
- Usually presents as a spontaneous acute vestibular syndrome
- HINTS exam is critical when evaluating patients with possible ischemia, and brain imaging should be obtained when central cause is suspected
- Treatment depends on etiology of ischemia and secondary prevention of strokes
- Less common etiologies include: Cerebellopontine angle tumors | Craniocervical dissection | Encephalitis | Intracranial hemorrhage | Meningitis | Multiple sclerosis | Seizures |Thiamine deficiency
KEY POINTS:
- The evaluation of patients with dizziness should include a thorough history taking coupled with a targeted physical exam, which when done correctly, can help distinguish between peripheral (and generally benign) causes of dizziness versus central (and possibly life threatening) etiologies
- Routine laboratory and imaging testing is not recommended in the absence of high clinical suspicion or a concerning exam finding
- The most common cause of peripheral dizziness is BPPV, which can be diagnosed via the Epley maneuver and treated successfully with canalith repositioning procedures
- The most common cause of central dizziness is vestibular migraine, and should be considered in patients who present with migraines and vertigo symptoms
Learn More – Primary Sources
AAFP: Dizziness: Evaluation and Management
BMJ Best Practice: Evaluation of Dizziness
Head-Impulse | Nystagmus | Test of skew
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