Dizziness

Undifferentiated dizziness is a high-risk symptom that can be caused by dysfunction of multiple organ systems. The assessment of dizziness focuses on key historical elements, along with reassuring or alarming physical exam findings. The patient’s dizziness symptoms should guide the physical exam; however, patients may have difficulty precisely describing their symptoms to fit into discreet entities such as vertigo, disequilibrium, presyncope, lightheadedness, or unsteadiness. More recently, diagnostic approaches have focused on the timing and triggers of dizziness. In this section, we will cover the following:

• Diagnostic Approach to Dizziness

• Benign Paroxysmal Positional Vertigo (BPPV)

• Vestibular Neuritis

• Ménière Disease

• Persistent Postural-Perceptual Dizziness (PPPD)

Diagnostic Approach to Dizziness

Although vestibular disorders are almost always associated with dizziness, most causes of dizziness are due to nonvestibular disorders. A cross-sectional study in an emergency department population showed that the most common causes were vasovagal syncope, fluid and electrolyte disorders, vestibular neuritis/labyrinthitis, arrhythmia, anemia, transient ischemic attack, hypoglycemia, and migraine.

The diagnosis is based on a detailed history and relevant physical exam findings (described below). Laboratory testing and electrocardiography may be helpful in select scenarios. The following algorithm is one approach for evaluating dizziness.

(Reprinted with permission from Dizziness: Approach to Evaluation and Management. American Family Physician Copyright © 2017 American Academy of Family Physicians. All Rights Reserved Am Fam Physician 2017.)

Key History Information

• Categorize the patient’s symptoms using their report of the timing (intermittent vs. continuous) and known triggers (precipitated by a certain movement or event):

  • triggered episodic vestibular syndrome: lasting seconds to minutes

  • spontaneous episodic vestibular syndrome: lasting minutes to hours

  • acute vestibular syndrome: spontaneous onset and constant vertiginous symptoms lasting hours to days

• Ask about the context of the dizziness, including provoking and alleviating factors.

• Assess cardiovascular risk factors, which increase suspicion for possible posterior circulation stroke affecting the vestibular system.

• Ask about associated hearing loss or tinnitus.

• Assess for additional neurologic symptoms that can suggest a central cause.

• Take a complete social history, including substance use.

• Review medications (especially antiepileptics, sedatives, antihypertensives, and analgesics, which are common causes of dizziness in the elderly).

Key Physical Exam Findings

• Assess vital signs; assess for orthostatic hypotension.

• Perform cardiac exam and evaluate the heart rate and rhythm. Assess for murmurs.

• Perform the HINTS exam, if you have a high suspicion for acute vestibular syndrome, to help distinguish between potential causes. In the acute setting, the three maneuvers in the HINTS exam are more sensitive than MRI for differentiating central causes (i.e., stroke or transient ischemic attack) vs. peripheral causes of acute vestibular syndrome. (View a video demonstration of the HINTS exam.)

  • Head Impulse: With the patient’s gaze fixed on an object in the distance, quickly turn the patient’s head 10 degrees in either direction. A normal result is the absence of catch-up saccades, which is also found in central vertigo. A corrective saccade (eyes turning with head and then returning to the distant object) is expected with peripheral causes.

  • Nystagmus: Vertical, torsional, and bidirectional nystagmus suggest a central cause. Spontaneous unidirectional horizontal nystagmus suggests a peripheral cause.

  • Test of Skew: With the patient looking straight ahead, alternate between covering and uncovering each eye. A vertical change in position of a covered eye after being uncovered is abnormal and suggests a central lesion.

• Perform the Dix-Hallpike maneuver if you suspect benign paroxysmal positional vertigo (see BPPV below).

• Evaluate gait: Inability to walk unsupported is a red flag for serious central pathology such as posterior circulation stroke.

• Perform a neurologic examination, including cranial nerve exam, strength examination, and sensory examination.

Pearls and Pitfalls

• Accurate differentiation between acute vestibular syndrome and spontaneous episodic vestibular syndrome may not be possible when a patient presents early in the course of vestibular syndrome.

• Vestibular syndromes are generally worse with head movement.

• Cerebellar signs are not always present in cerebellar infarcts.

• Benign paroxysmal positional vertigo (BPPV) in the elderly can be triggered with position change, which can incorrectly lead you to suspect hypovolemia and mislead you toward a diagnosis of orthostasis.

• Beware of anchoring bias toward a specific diagnosis before seeing the patient (e.g., assuming BPPV as the cause of dizziness).

(Adapted from Diagnosing Stroke in Acute Dizziness and Vertigo: Pitfalls and Pearls. Stroke 2018.)

Benign Paroxysmal Positional Vertigo

Benign paroxysmal positional vertigo (BPPV) is a common cause of dizziness and the most common cause of vertigo. It is usually triggered by head movement, and the symptoms last a few seconds to minutes. The three types of BPPV are named for the involved semicircular canal: posterior, horizontal, and anterior. Posterior and horizontal canal BPPV account for almost all cases, with posterior being the most common. BPPV is treated with repositioning maneuvers. A successful repositioning maneuver also rules out other diagnoses. Consider a central cause of dizziness if the patient has associated neurologic symptoms or certain features of nystagmus as outlined above in Key Physical Examination Findings.

Posterior canal BPPV: The Dix-Hallpike maneuver (figure 1 below) is used to diagnose posterior canal BPPV. The Epley maneuver (figure 2 below) and the Semont maneuver (figure 3 below) are used to treat posterior canal BPPV. The nystagmus in posterior canal BPPV develops after a short latency period and resolves within 60 seconds; it reverses direction when the patient sits up and diminishes with repeat testing (i.e., fatigability).

(Source: Benign Paroxysmal Positional Vertigo. N Engl J Med 2014.)

(Source: Benign Paroxysmal Positional Vertigo. N Engl J Med 2014.)

(Source: Benign Paroxysmal Positional Vertigo. N Engl J Med 2014.)

Horizontal canal BPPV and posterior canal BPPV have similar manifestations, but horizontal canal BPPV is diagnosed with the supine log-roll test and treated with the Gufoni maneuver.

Vestibular Neuritis

Differentiating between vestibular neuritis and vestibular labyrinthitis is dependent on the presence or absence of hearing loss. Vestibular neuritis is a common cause of acute vestibular syndrome with preserved hearing. The vertiginous symptoms can be abrupt or gradual in onset and last for a few days. BPPV can develop in about 15% of patients after an episode of vestibular neuritis. Reactivation of type 1 herpes simplex virus is thought to be the primary etiology, but antivirals (e.g., valacyclovir) have not been shown to be beneficial. The mainstay of treatment is symptom control with antihistamines, anticholinergics, and benzodiazepines. Vestibular rehabilitation helps improve balance, and glucocorticoids may improve vestibular recovery.

Vestibular labyrinthitis refers to acute vestibular syndrome with hearing loss. It is thought to be closely related to vestibular neuritis; however, some experts advise caution with this diagnosis because the clinical picture can be a dangerous mimic of anterior inferior cerebellar artery ischemia. Consider specialist consultation for specialized vestibular testing.

Ménière Disease

Ménière disease is a diagnosis of exclusion and can only be diagnosed after repeated episodes of vertigo with other otologic features. Ménière disease consists of the triad of tinnitus, hearing loss, and vertigo and is thought to be due to endolymphatic hydrops, whereas Ménière syndrome demonstrates the same triad of symptoms but is due to another otologic abnormality of the inner ear.

The American Academy of Otolaryngology-Head and Neck Surgery defines Ménière disease as follows:

• two or more spontaneous episodes of vertigo, each lasting 20 minutes to 12 hours

• audiometrically documented sensorineural hearing loss in the affected ear

• fluctuating aural symptoms (hearing, tinnitus, or aural fullness) in the affected ear

• not accounted for by another vestibular diagnosis

Endolymphatic hydrops is the presumed pathology of Ménière disease, but the underlying causes are elusive. Specialist referral is almost always required to guide diagnostic workup. Once diagnosed, treatment is based on symptomatic management of acute episodes of vertigo, dietary modification (e.g., limiting salt, caffeine, and alcohol), and occasionally diuretics (theoretically to reduce endolymphatic hydrops), betahistine, and glucocorticoids. Surgery and ablative procedures may be considered in select patients.

Persistent Postural-Perceptual Dizziness

Persistent postural-perceptual dizziness (PPPD; formerly known as chronic subjective dizziness) is a diagnosis of exclusion characterized by at least 3 months of nonvertiginous, persistent dizziness or imbalance that occurs on most days and is often provoked by patient motion and upright positioning as well as moving objects in the environment. Patients often suffer from comorbid anxiety or other psychiatric disease. PPPD is often preceded by central nervous system (CNS) trauma, infection, or other vestibular disorders. Vestibular rehabilitation, reassurance, cognitive behavioral therapy, and treatment of comorbid psychiatric conditions are the mainstays of treatment. Vestibular and balance rehabilitation therapy (VBRT) is an effective treatment for PPPD and other forms of dizziness and may be delivered via the internet or in person, typically by physical and occupational therapists.