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An ever-common chief complaint in primary care, urgent care, emergency departments, and even at specialist clinics is dizziness. There is a high likelihood that as a student you have at least seen one patient with dizziness, as a practicing clinician you have probably seen a plethora of cases, and as a patient, you may have suffered from this concern.
The chief complaint of dizziness is often quite vague, and may require no work up, but could require quite an extensive diagnostic evaluation. My job today is to help give options for the evaluation of dizziness as well as the management.
If you are working or rotating in primary care, you will see over one-half of the patients who have the chief complaint of dizziness.1 The underlying cause of a patient’s symptoms can be a myriad of things. Below is a list of common causes of dizziness, but by no means is it fully comprehensive.
Any one etiology for dizziness has been found to make up no more than 10 percent of total cases of dizziness.1 Due to the wide variability of causes of dizziness that a patient may have, it is the clinician's job to quickly determine if the underlying cause is benign, or if there are concerns of a more ominous etiology that requires expedited workup or transfer of care to the emergency department.
Eliciting The History
It is always important just like with each patient to complete a full history and physical examination. Often, information garnered within the history taking may aid in diagnosis. Relevant questions may include the onset and duration of symptoms and triggers (specific movements or situations). A newer model for the approach to determining the underlying etiology of dizziness is the TiTrATE method, which includes:
- Timing of the symptoms
- Triggers that cause the symptoms to occur
- And Targeted Examination
The response to this questioning and examination, place a patient’s dizziness into one of three categories: spontaneous episodic, episodic triggered, or continuous vestibular.
Episodic triggered symptoms will often present with brief intermittent periods of dizziness that last seconds to hours. Triggers may include head motion with a change of body position, such as when rolling over in bed. Episodic triggered symptoms are often related to benign paroxysmal positional vertigo (BPPV).
Spontaneous episodic symptoms will often present with a patient having episodes of dizziness lasting seconds to days without any specific trigger found. Since there are no known triggers, the history is often the key to diagnosis. Common possible etiologies may include vestibular migraines, Meniere disease, or psychiatric conditions like anxiety. If symptoms occur when the patient is lying down, they are more likely to be vestibular in origin.
In continuous vestibular causes, a patient’s symptoms will be persistent, lasting several days to weeks and can be caused by traumatic or toxic exposure. Classic symptoms along with the persistent dizziness may include nausea, vomiting, nystagmus, head-motion intolerance, and unstable gait. If there are no historical findings of traumatic or toxic exposure, then the cause is most likely vestibular neuritis verses a central etiology. However, central etiologies may often have symptoms present that are triggered by movement.
Another common cause of the complaint of dizziness is vertigo. If a patient notes that they have complaints of dizziness with subjective self-motion when they are not moving, they may be suffering from vertigo. Vertigo is often due to an asymmetry in the vestibular system or disease in the peripheral labyrinth.
If the patient describes vertigo, you should ask about hearing loss which could point towards Meniere disease. If vertiginous symptoms are reproduced with positional changes or certain positions, then BPPV should be considered. Orthostatic hypotension may be another cause of vertigo, in which a patient becomes symptomatic with quick movements from supine to sitting, sitting to standing, or supine to standing quickly.
Medications and Vertigo
Medications can also be a cause of dizziness. It has been seen that medications or polypharmacy was implicated in 23 percent of cases in older adults in a primary care setting.1 Using five or more medications has been found to increase the risk of dizziness. Below is a table of several medications and substances that can lead to complaints of dizziness.
The Physical Exam
A full physical examination should be completed, with a particular focus on the neurologic, cardiovascular, and HEENT examinations. Blood pressure should be measured along with orthostatic vital signs. Orthostatic hypotension is diagnosed when the systolic blood pressure drops by at least 20 mmHg, diastolic blood pressure drops by at least 10 mmHg, or the pulse increased by 30 bpm after going from supine to standing for a minute duration.
A patient’s gait, balance, and Romberg testing should be completed. Those with an unsteady gait should be assessed for peripheral neuropathy. If Romberg testing is positive, this suggests an abnormality with proprioception receptors or the pathways of proprioception.1
The use of the HINTS examination can help determine a possible concerning central etiology versus a less ominous peripheral cause of dizziness. HINTS stands for: Head-Impulse, Nystagmus, Test of Skew.
Head impulse is tested with the patient sitting, then thrusting the head 10 degrees to the right, and then to the left while the patient is focusing on the provider’s nose. If rapid eye movement is seen in both eyes, the etiology is likely peripheral. If no eye movement is seen, the etiology is likely central.
Nystagmus is tested by the patient following the provider’s finger with their eyes to the left and right. Unidirectional horizontal nystagmus that gets worse when the patient is gazing in the direction of the nystagmus is most consistent with a peripheral cause. If there is spontaneous nystagmus that is vertical or torsional or that changes with the direction of gaze, this is most consistent with a central etiology.
Test of skew is tested by asking the patient to look straight forward then covering and uncovering each eye. Vertical deviation of the covered eye after uncovering is an abnormal finding, and may be associated with a central etiology or brainstem involvement.
Another physical examination that should be completed in the assessment of dizziness is the Dix-Hallpike maneuver. If there is transient upbeat or torsional nystagmus during the maneuver, this is diagnostic for BPPV if the timing and trigger are consistent with BPPV. If a patient has positive results on Dix-Hallpike testing, but does not have timing or characteristics of BPPV, assessment for a central etiology should be completed.
Some patients who present with complaints of dizziness will not need laboratory testing. However, most patients will have a comorbidity such as diabetes, hypertension, or heart disease, which may require testing such as a CBC, CMP, TSH, UA, and EKG. Other testing that should be considered based on history and physical examination findings include a urine drug screen, BNP, magnesium, vitamin D, vitamin B12, folate, echocardiogram, Holter monitor, carotid artery ultrasound, or cardiac stress testing.
Regular neuroimaging is not indicated in most cases of dizziness. However, if there are any neurologic testing abnormalities on examination or asymmetric hearing loss, a CT scan or MRI should be completed to assess for cerebrovascular disease. If there is dizziness, with hearing loss and normal imaging results, this suggests Meniere disease.
Stay tuned for the next article which will discuss specific diagnoses and treatments of dizziness!
- Am Fam Physician. Dizziness: Approach to Evaluation and Management. 2017;95(3):154-162. Copyright © 2017 American Academy of Family Physicians.
- UpToDate. Approach to the Patient with Dizziness. Accessed: August 15, 2018.