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Dizziness: Approach to Evaluation and Management HERBERT L Dizziness: Approach to Evaluation and Management HERBERT L. MUNCIE, MD, Louisiana State University School of Medicine, New Orleans, Louisiana SUSAN M. SIRMANS, PharmD, University of Louisiana at Monroe School of Pharmacy, Monroe, Louisiana ERNEST JAMES, MD, Louisiana State University School of Medicine, New Orleans, Louisiana Dizziness is a common yet imprecise symptom. It was traditionally divided into four categories based on the patient’s history: vertigo, presyncope, disequilibrium, and light-headedness. However, the distinction between these symp- toms is of limited clinical usefulness. Patients have difficulty describing the quality of their symptoms but can more consistently identify the timing and triggers. Episodic vertigo triggered by head motion may be due to benign parox- ysmal positional vertigo. Vertigo with unilateral hearing loss suggests Meniere disease. Episodic vertigo not associated with any trigger may be a symptom of vestibular neuritis. Evaluation focuses on determining whether the etiology is peripheral or central. Peripheral etiologies are usually benign. Central etiologies often require urgent treatment. The HINTS (head-impulse, nystagmus, test of skew) examination can help distinguish peripheral from central etiologies. The physical examination includes orthostatic blood pressure measurement, a full cardiac and neurologic examina- tion, assessment for nystagmus, and the Dix-Hallpike maneuver. Laboratory testing and imaging are not required and are usually not helpful. Benign paroxysmal positional vertigo can be treated with a canalith repositioning procedure (e.g., Epley maneuver). Treatment of Meniere disease includes salt restriction and diuretics. Symptoms of vestibu- lar neuritis are relieved with vestibular suppressant medications and vestibular rehabilitation. (Am Fam Physician. 2017;95(3):154-162. Copyright © 2017 American Academy of Family Physicians.) CME This clinical content izziness is a common yet im­ and triggers of dizziness is preferred over the conforms to AAFP criteria precise symptom often en­ symptom type because patients more consis­ for continuing medical 3,7 education (CME). See coun tered by family physicians. tently report this information. CME Quiz Questions on Primary care physicians see at page 149. Dleast one­half of the patients who present General Approach 1 Author disclosure: No rel- with dizziness. The differential diagnosis is Questions regarding the timing (onset, evant financial affiliations. broad, with each of the common etiologies duration, and evolution of dizziness) and ▲ 2 Patient information: accounting for no more than 10% of cases triggers (actions, movements, or situations) A handout on this topic, (Table 11,3). Because the symptoms are vague, that provoke dizziness can categorize the written by the authors of physicians must distinguish benign from se­ dizziness as more likely to be peripheral or this article, is available rious causes that require urgent evaluation central in etiology. Findings from the physi­ at http://www.aafp.org/ afp/2017/0201/p154-s1. and treatment. cal examination can help confirm a probable html. Dizziness was traditionally classified diagnosis. A diagnostic algorithm can help into four categories based on the patient’s determine whether the etiology is peripheral description: (1) vertigo, (2) presyncope, (3) or central (Figure 1). disequilibrium, and (4) light­headedness.4 However, current approaches do not include TITRATE THE EVALUATION presyncope and do not use the vague term TiTrATE is a novel diagnostic approach to light­headedness.5 Patients often have dif­ determining the probable etiology of diz­ ficulty describing their symptoms and may ziness or vertigo.2 The approach uses the give conflicting accounts at different times.3 Timing of the symptom, the Triggers that Symptom quality does not reliably predict provoke the symptom, And a Targeted the cause of dizziness.6 Physicians are cau­ Examination. The responses place the diz­ tioned against overreliance on a descriptive ziness into one of three clinical scenarios: approach to guide the diagnostic evalua­ episodic triggered, spontaneous episodic, or tion.7 Alternatively, attention to the timing continuous vestibular. 154Downloaded American from the Family American Physician Family Physician website at www.aafp.org/afp.www.aafp.org/afp Copyright © 2017 American AcademyVolume of Family 95, Physicians. Number For3 ◆the February private, noncom 1, 2017- mercial use of one individual user of the website. All other rights reserved. Contact [email protected] for copyright questions and/or permission requests. Dizziness SORT: KEY RECOMMENDATIONS FOR PRACTICE Evidence Clinical recommendation rating References Vertigo associated with unilateral hearing loss should raise suspicion for Meniere disease. C 41 The physical examination in patients with dizziness should include orthostatic blood pressure measurement, C 16 nystagmus assessment, and the Dix-Hallpike maneuver for triggered vertigo. The HINTS (head-impulse, nystagmus, test of skew) examination can help differentiate a peripheral cause of C 20 vestibular neuritis from a central cause. Laboratory testing and imaging are not recommended when no neurologic abnormality is found on examination. C 1 Benign paroxysmal positional vertigo is treated with a canalith repositioning procedure (e.g., Epley maneuver). A 30 Vestibular neuritis symptoms may be relieved with medication and vestibular rehabilitation. C 20 Meniere disease may improve with a low-salt diet and diuretic use. B 41 A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to http://www.aafp.org/afpsort. With episodic triggered symptoms, patients Table 1. Differential Diagnosis of Dizziness and Vertigo: have brief episodes of intermittent dizziness Common Causes lasting seconds to hours. Common triggers are head motion on change of body position Cause (most to (e.g., rolling over in bed). Episodic triggered least frequent) Clinical description symptoms are consistent with a diagnosis of Peripheral causes benign paroxysmal positional vertigo (BPPV). Benign paroxysmal Transient triggered episodes of vertigo caused by With spontaneous episodic symptoms (no positional vertigo dislodged canaliths in the semicircular canals trigger), patients have episodes of dizziness Vestibular neuritis Spontaneous episodes of vertigo caused by lasting seconds to days. Because these epi­ inflammation of the vestibular nerve or sodes have no trigger, the patient’s history labyrinthine organs, usually from a viral infection establishes the diagnosis. Common diagnos­ Meniere disease Spontaneous episodes of vertigo associated tic considerations for spontaneous episodic with unilateral hearing loss caused by excess endolymphatic fluid pressure in the inner ear symptoms include Meniere disease, vestibu­ Otosclerosis Spontaneous episodes of vertigo caused by lar migraine, and psychiatric diagnoses such abnormal bone growth in the middle ear and as anxiety disorders. Symptoms associated associated with conductive hearing loss with lying down are more likely vestibular. Central causes With continuous vestibular symptoms, Vestibular migraine Spontaneous episodes of vertigo associated with patients have persistent dizziness lasting migraine headaches days to weeks. The symptoms may be due to Cerebrovascular disease Continuous spontaneous episodes of vertigo traumatic or toxic exposure. Classic vestibu­ caused by arterial occlusion or insufficiency, especially affecting the vertebrobasilar system lar symptoms include continuous dizziness Cerebellopontine angle Continuous spontaneous episodes of dizziness or vertigo associated with nausea, vomiting, and posterior fossa caused by vestibular schwannoma (i.e., acoustic nystagmus, gait instability, and head­motion meningiomas neuroma), infratentorial ependymoma, brainstem intolerance. In the absence of trauma or glioma, medulloblastoma, or neurofibromatosis exposures, these findings are most consistent Other causes with vestibular neuritis or central etiologies. Psychiatric Initially episodic, then often continuous episodes of However, central causes can also occur with dizziness without another cause and associated with psychiatric condition (e.g., anxiety, patterns triggered by movement. depression, bipolar disorder) HISTORY: TIMING, TRIGGERS, Medication induced Continuous episodes of dizziness without another AND MEDICATIONS cause and associated with a possible medication adverse effect Patients who describe a sensation of self­ Cardiovascular/ Acute episodic symptoms that are not associated motion when they are not moving or a sensa­ metabolic with any triggers tion of distorted self­motion during normal Orthostatic Acute episodic symptoms associated with a change 5 in position from supine or sitting to standing head movement may have vertigo. Vertigo is the result of asymmetry within the ves­ Information from references 1 and 3. tibular system or a disorder of the peripheral labyrinth or its central connections.8,9 The February 1, 2017 ◆ Volume 95, Number 3 www.aafp.org/afp American Family Physician 155 Dizziness Assessment of Dizziness Patient presents with dizziness or vertigo Is the timing episodic or continuous? Episodic Continuous Is it triggered or spontaneous? Is it associated with trauma or toxins, or spontaneous? Triggered* Spontaneous
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