Dizziness: Approach to Evaluation and Management

 

Am Fam Physician. 2017 Feb 1;95(3):154-162.

  Patient information: See related handout on dizziness, written by the authors of this article.

Author disclosure: No relevant financial affiliations.

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 symptoms 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 paroxysmal 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 examination, 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 vestibular neuritis are relieved with vestibular suppressant medications and vestibular rehabilitation.

Dizziness is a common yet imprecise symptom often encountered by family physicians. Primary care physicians see at least one-half of the patients who present with dizziness.1 The differential diagnosis is broad, with each of the common etiologies accounting for no more than 10% of cases2  (Table 11,3). Because the symptoms are vague, physicians must distinguish benign from serious causes that require urgent evaluation and treatment.

WHAT IS NEW ON THIS TOPIC: EVALUATION OF DIZZINESS

TiTrATE is a novel diagnostic approach to determine the probable etiology of dizziness or vertigo. It uses the Timing of the symptom, the Triggers that provoke the symptom, And a Targeted Examination. The patient's response determines the classification of dizziness as episodic triggered, spontaneous episodic, or continuous vestibular.

In a study of older patients in a primary care setting, medications were implicated in 23% of cases of dizziness.

The HINTS (head-impulse, nystagmus, test of skew) examination can help differentiate a peripheral cause of vestibular neuritis from a central cause.

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SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferences

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, nystagmus assessment, and the Dix-Hallpike maneuver for triggered vertigo.

C

16

The HINTS (head-impulse, nystagmus, test of skew) examination can help differentiate a peripheral cause of vestibular neuritis from a central cause.

C

20

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.

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferences

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, nystagmus assessment, and the Dix-Hallpike maneuver for triggered vertigo.

C

16

The HINTS (head-impulse, nystagmus, test of skew) examination can help differentiate a peripheral cause of vestibular neuritis from a central cause.

C

20

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 Authors

show all author info

HERBERT L. MUNCIE, MD, is a professor in the Department of Family Medicine at Louisiana State University School of Medicine, New Orleans....

SUSAN M. SIRMANS, PharmD, is an associate professor in the Department of Clinical Sciences at the University of Louisiana at Monroe School of Pharmacy.

ERNEST JAMES, MD, is an assistant professor in the Department of Family Medicine at Louisiana State University School of Medicine.

Address correspondence to Herbert L. Muncie, MD, LSU School of Medicine, 2020 Gravier St., Ste. 746, New Orleans, LA 70112 (e-mail: hmunci@lsuhsc.edu). Reprints are not available from the authors.

Author disclosure: No relevant financial affiliations.

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