12.05.

2017 Dzzness:ADagnostcApproachAmercanFamlyPhyscan

Dizziness:ADiagnosticApproach
Amorerecentarticleondizzinessisavailable(http://www.aafp.org/afp/2017/0201/p154.html).

ROBERTE.POST,MD,VirtuaFamilyMedicineResidency,Voorhees,NewJersey
LORIM.DICKERSON,PharmD,MedicalUniversityofSouthCarolina,Charleston,SouthCarolina
AmFamPhysician.2010Aug1582(4):361368.

Patientinformation:Seerelatedhandoutondizziness(http://www.aafp.org/afp/2010/0815/p369.html),writtenbytheauthorsofthisarticle.

Dizzinessaccountsforanestimated5percentofprimarycareclinicvisits.Thepatienthistorycangenerallyclassifydizzinessintooneoffour
categories:vertigo,disequilibrium,presyncope,orlightheadedness.Themaincausesofvertigoarebenignparoxysmalpositionalvertigo,Meniere
disease,vestibularneuritis,andlabyrinthitis.Manymedicationscancausepresyncope,andregimensshouldbeassessedinpatientswiththistypeof
dizziness.Parkinsondiseaseanddiabeticneuropathyshouldbeconsideredwiththediagnosisofdisequilibrium.Psychiatricdisorders,suchas
depression,anxiety,andhyperventilationsyndrome,cancausevaguelightheadedness.Thedifferentialdiagnosisofdizzinesscanbenarrowedwith
easytoperformphysicalexaminationtests,includingevaluationfornystagmus,theDixHallpikemaneuver,andorthostaticbloodpressuretesting.
Laboratorytestingandradiographyplaylittleroleindiagnosis.Afinaldiagnosisisnotobtainedinabout20percentofcases.Treatmentofvertigo
includestheEpleymaneuver(canalithrepositioning)andvestibularrehabilitationforbenignparoxysmalpositionalvertigo,intratympanic
dexamethasoneorgentamicinforMenieredisease,andsteroidsforvestibularneuritis.Orthostatichypotensionthatcausespresyncopecanbe
treatedwithalphaagonists,mineralocorticoids,orlifestylechanges.Disequilibriumandlightheadednesscanbealleviatedbytreatingtheunderlying
cause.

Diagnosingthecauseofdizzinesscanbedifficultbecausesymptomsareoftennonspecificandthedifferentialdiagnosisisbroad.However,afewsimplequestions
andphysicalexaminationtestscanhelpnarrowthepossiblediagnoses.Itisestimatedthatprimarycarephysicianscareformorethanonehalfofallpatientswho
presentwithdizziness.1Dizzinessisthechiefpresentingsymptominabout3percentofprimarycarevisitsforpatients25yearsandolder,andinnearly3percent
ofallemergencydepartmentvisits.2,3

Dizzinesscanbeclassifiedintofourmaintypes:vertigo,disequilibrium,presyncope,orlightheadedness.Althoughappropriatehistoryandphysicalexamination
usuallyleadstoadiagnosis,thefinalcauseofdizzinessisnotidentifiedinuptooneinfivepatients.4,5

View/PrintTable

SORT:KEYRECCOMENDATIONSFORPRACTICE
EVIDENCE
CLINICALRECOMMENDATION REFERENCES
RATING

TheDixHallpikemaneuvershouldbeperformedtodiagnoseBPPV. C 7,9,16

Becausetheygenerallyarenothelpfuldiagnostically,laboratorytestingandradiographyarenotroutinelyindicatedintheworkupofpatients C 7,31,32
withdizzinesswhennootherneurologicabnormalitiesarepresent.

TheEpleymaneuverandvestibularrehabilitationareeffectivetreatmentsforBPPV. B 40,41,42

BPPV=benignparoxysmalpositionalvertigo.

A=consistent,goodqualitypatientorientedevidenceB=inconsistentorlimitedqualitypatientorientedevidenceC=consensus,diseaseorientedevidence,usualpractice,expert
opinion,orcaseseries.ForinformationabouttheSORTevidenceratingsystem,gotohttp://www.aafp.org/afpsort.xml(http://www.aafp.org/afpsort.xml).

PatientHistory
Theinitialdescriptionofdizzinesscanbedifficulttoobtainbecausepatientresponsesarenotalwaysconsistent.6Therefore,thehistoryshouldfirstfocusonwhat
typeofsensationthepatientisfeeling.Table1includesdescriptorsforthemaincategoriesofdizziness.4,5,7,8Itisimportanttonotethatsomecausesofdizziness
canbeassociatedwithmorethanonesetofdescriptors.

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Table1.
MainCategoriesofDizziness
CATEGORY DESCRIPTION PERCENTAGEOFPATIENTSWITHDIZZINESS

Vertigo Falsesenseofmotion,possiblyspinningsensation 45to54

Disequilibrium Offbalanceorwobbly Upto16

Presyncope Feelingoflosingconsciousnessorblackingout Upto14

Lightheadedness Vaguesymptoms,possiblyfeelingdisconnectedwiththeenvironment Approximately10

Informationfromreferences4,5,7,and8.

Amedicationhistoryshouldbeobtainedbecausedizziness(especiallyfromorthostatichypotension)isawellknownadverseeffectofmanydrugs9(Table210,11).
Patientsshouldalsobeaskedaboutcaffeine,nicotine,andalcoholintake.9Headtraumaandwhiplashinjuriescancauseavarietyofdizzinesssymptoms,from
vertigotolightheadedness.Theincidenceofdizzinesswithaheadinjuryorvertigoinitiallyafterwhiplashhavebeenreportedashighas78to80percent.12
SelectedcausesofdizzinessaresummarizedinTable3.4,7,8,1320

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Table2.
MedicationsCommonlyAssociatedwithDizzinessfromOrthostaticHypotension

Cardiacmedications

Alphablockers(e.g.,doxazosin[Cardura],terazosin)

Alpha/betablockers(e.g.,carvedilol[Coreg],labetalol)

Angiotensinconvertingenzymeinhibitors

Betablockers

Clonidine(Catapres)

Dipyridamole(Persantine)

Diuretics(e.g.,furosemide[Lasix])

Hydralazine

Methyldopa

Nitrates(e.g.,nitroglycerinpaste,sublingualnitroglycerin)

Reserpine

Centralnervoussystemmedications

Antipsychotics(e.g.,chlorpromazine,clozapine[Clozaril],thioridazine)

View/PrintTable

Table3.
SelectedCausesofDizziness
CATEGORYOF
CAUSE PATHOPHYSIOLOGY DIAGNOSTICCRITERIA
DIZZINESS

Benign Vertigo Looseotolithinsemicircularcanalscausingafalsesenseof PositivefindingswithDixHallpikemaneuverepisodic

paroxysmal motion vertigowithouthearingloss
positional
vertigo

Hyperventilation Lightheadedness Hyperventilationcausingrespiratoryalkalosisunderlying Symptomsreproducedwithvoluntaryhyperventilation

syndrome anxietymayprovokethehyperventilation

Meniere Vertigo Increasedendolymphaticfluidintheinnerear Episodicvertigowithhearingloss

disease

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CATEGORYOF
CAUSE PATHOPHYSIOLOGY DIAGNOSTICCRITERIA
DIZZINESS

Migrainous Vertigo Uncertainonehypothesisisthattrigeminalnuclei Episodicvertigowithsignsofmigraine,plusphotophobia,

vertigo stimulationcausesnystagmusinpersonswithmigraine phonophobia,orauraduringatleasttwoepisodesofvertigo
(vestibular
migraine)

Orthostatic Presyncope Dropinbloodpressureonpositionchangecausing Systolicbloodpressuredecreaseof20mmHg,diastolic

hypotension decreasedbloodflowtothebrain,adverseeffectofmultiple bloodpressuredecreaseof10mmHg,orapulseincreaseof
medications(seeTable2) 30beatsperminute

Parkinson Disequilibrium Dysfunctioningaitcausingimbalanceandfalls Shufflinggaitwithreducedarmswingandpossiblehesitation

disease

VERTIGO
Otologicorvestibularcausesofvertigoarethemostcommoncausesofdizziness,21,22andincludebenignparoxysmalpositionalvertigo(BPPV),vestibularneuritis
(viralinfectionofthevestibularnerve),labyrinthitis(infectionofthelabyrinthineorgans),andMenieredisease(increasedendolymphaticfluidintheinnerear).7,13
Anestimated35percentofadults40yearsandolderhavevestibulardysfunction.14

Hearinglossanddurationofsymptomshelpnarrowthedifferentialdiagnosisfurtherinpatientswithvertigo.VertigowithhearinglossisusuallycausedbyMeniere
diseaseorlabyrinthitis,whereasvertigowithouthearinglossismorelikelycausedbyBPPVorvestibularneuritis.8Unilateralauditorysymptomshelplocalizethe
causetoananatomicabnormality,particularlyinpatientswithperipheraldisease.9EpisodicvertigotendstobecausedbyBPPVorMenieredisease,whereas
persistentvertigocanbecausedbyvestibularneuritisorlabyrinthitis.8

Migrainousvertigo,orvestibularmigraine,isanotherunderlyingcauseofvertigothataffectsabout3percentofthegeneralpopulationandabout10percentof
personswithmigraine.15Thisdiagnosisshouldbeconsideredafterothercausesofvertigohavebeenruledout.Diagnosisofmigrainousvertigoisestablishedin
patientswithahistoryofepisodicvertigowithacurrentmigraineorhistoryofmigraineandoneofthefollowingsymptomsduringatleasttwoepisodesofvertigo:
migraineheadache,photophobia,phonophobia,oraura.15

PRESYNCOPE
Cardiovascularcausesofdizzinessincludearrhythmias,myocardialinfarction,carotidarterystenosis,andorthostatichypotension.21Ofpatientswith
supraventriculartachycardia,75percentexperiencedizzinessandabout30percentexperiencesyncope.23Symptomsbroughtonbyposturalchangessuggesta
diagnosisoforthostatichypotension.9Avarietyofcardiovascularmedicationsincreasetheriskoforthostatichypotensioninolderpersons,includingreserpine(at
dosesgreaterthan0.25mg),doxazosin(Cardura),andclonidine(Catapres).24

DISEQUILIBRIUM
Therearemanyunderlyingconditionsthatmaycauseasenseofimbalance.Strokeisanimportantandlifethreateningcauseofdizzinessthatneedstoberuled
outwhenthedizzinessisassociatedwithothersymptomsofstroke.However,otherneurologicfindingsaregenerallypresent.Inapopulationbasedstudyofmore
than1,600patients,3.2percentofthosepresentingtoanemergencydepartmentwithdizzinesswerediagnosedwithastrokeortransientischemicattack(TIA),
butonly0.7percentpresentingwithisolateddizzinesswerediagnosedwithstrokeorTIA.25

Poorvisioncommonlyaccompaniesafeelingofimbalance,16leadingtofalls.Thephysicianshouldinquireaboutahistoryofotherproblemsthatmaycause
imbalance,suchasParkinsondisease,peripheralneuropathy,andanymusculoskeletaldisordersthatmayaffectgait.17Useofbenzodiazepinesandtricyclic
antidepressantsincreasetheriskofataxiaandfallsinolderpersons.24

LIGHTHEADEDNESS
Psychiatriccausesoflightheadednessarecommon,particularlyanxietytherefore,questionsaboutanxietyanddepressionshouldbeincludedinthepatienthistory.
Inonestudy,about28percentofpatientswithdizzinessreportedsymptomsofatleastoneanxietydisorder.26Inanotherstudy,oneinfourpatientswithdizziness
metcriteriaforpanicdisorder.27Astudyofpatientswithchronicdizzinessshowedthatthosewithpanicdisorderweremorelikelytohaveneurotologicfindingsthan
thosewithoutpanicdisorder.28Upto60percentofpatientswithchronicsubjectivedizzinesshavebeenreportedtohaveananxietydisorder.29Depressionand
alcoholintoxicationhavealsobeenfoundtooverlapwithdizziness.21,30

Hyperventilationsyndromeisanimportantcauseoflightheadedness.Althoughtheconditioncanbeassociatedwithanxietydisorders,manypatientswithout
anxietyexperiencehyperventilation.Hyperventilationisdefinedasbreathinginexcessofmetabolicrequirements,causingarespiratoryalkalosisand
lightheadedness.Patientsmaysighrepeatedlyandmayhaveassociatedsymptoms,suchaschestpain,paraesthesias,bloating,andepigastricpain.18

PhysicalExamination
Themaingoalofthephysicalexaminationistoreproducethepatient'sdizzinessintheoffice.Thereareafewsimplephysicalexaminationteststhatcanbe
performedtoaidinthisgoal.

First,bloodpressureshouldbemeasuredwhilethepatientisinasupinepositionandagainatleastoneminuteafterthepatientstands.Asystolicbloodpressure
decreaseof20mmHg,diastolicbloodpressuredecreaseof10mmHg,orpulseincreaseof30beatsperminuteisindicativeoforthostatichypotension.16,19

TheDixHallpikemaneuver(Figure19,16)isdiagnosticforBPPVifpositive,butdoesnotruleitoutifnegative.Themaneuverisperformedonaflatexamination
table.Whilethepatientisinaseatedposition,thephysicianturnsthepatient'shead45degreestooneside,thenrapidlylaysthepatientintoasupinepositionwith
theheadhangingabout20degreesovertheendofthetableandobservesthepatient'seyesforapproximately30seconds.Themaneuverisrepeatedwiththe
headturnedtotheoppositeside.Nystagmusisdiagnosticofvestibulardebrisintheearthatisfacingdown,closesttotheexaminationtable.Thereisusuallya
latentperiodofafewsecondsbeforethepatientdevelopsnystagmus,andasensationofvertigoforuptooneminute.9,16ThesensitivityoftheDixHallpike
maneuveris50to88percentforBPPV.7

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 12.05.2017 Dzzness:ADagnostcApproachAmercanFamlyPhyscan

Figure1.

DixHallpikemaneuver.Whilethepatientisinaseatedposition,thephysician(A)turnsthepatient'shead45degreestooneside,then(B)rapidlylaysthepatientintoasupine
positionwiththeheadhangingabout20degreesovertheendofthetable,observingthepatient'seyesforapproximately30seconds.Themaneuverisrepeatedfortheopposite
side.Nystagmusisdiagnosticofvestibulardebrisintheearthatisfacingdown,closesttotheexaminationtable.Avideodemonstrationofthismaneuverisavailableat
http://www.youtube.com/watch?v=vRpwf2mI3SU(http://www.youtube.com/watch?v=vRpwf2mI3SU).

Informationfromreferences9and16.

LesionsofthelabyrinthandcranialnerveVIII(vestibulocochlear)commonlyproducespontaneousnystagmus.Saccadiceyemovementsassociatedwithapatient's
smoothocularpursuitofthephysician'sfingerasitmovesslowlyleft,right,up,anddownmaybeassociatedwithacentralcause,suchasbrainstemorcerebellar
disease.Theheadimpulsetestinvolvesaskingthepatienttoremainfocusedonatargetwhilethephysicianmovesthepatient'sheadbackandforthrapidly.Eye
movementtoonesidewitharefixationsaccade(rapidoscillatoryeyemovementthatoccursastheeyefixesonanobject)isindicativeofalesiononthesideto
whichtheeyesmove.Bilateralrefixationmovementscommonlyoccurwithototoxicity.Anothertestthatcanelicitnystagmusinvolvesthepatientleaningforward30
degreeswhilethephysicianshakesthepatient'sheadbackandforthvigorouslyfor20seconds.Thepresenceofnystagmusindicatesaperipheralcauseinthe
ipsilateraldirectionofthenystagmus.9

OtherphysicalexaminationtestsincludetheRombergtestandobservationofgait.SwayingtowardonesidewiththeRombergtestisindicativeofvestibular
dysfunctionintheipsilateralside.Also,apatient'sgaitwillleantowardthesideofavestibularlesion.Ataxiaisindicativeofcerebellardysfunction,andthepatient's
gaitisusuallyslow,widebased,andirregular.9,20Observationofgaitisalsoimportanttodetectsymptomssuggestiveofparkinsonisminpatientspresentingwith
disequilibrium.4InearlyParkinsondisease,gaitisusuallyslowerwithsmallerstepsandreducedarmswing,andprogressestofreezingandhesitationinlater
stagesofthedisease.20Screeningforperipheralneuropathyisalsoimportantinpatientspresentingwithdisequilibrium.4

Ifhyperventilationsyndromeissuspected,thediagnosiscanbeconfirmedbyhavingthepatientrapidlytake20deepinhalationsandexhalations,inanattemptto
reproducesymptoms.9,18

Athoroughcardiovascularexaminationshouldbeperformedinallpatientswithdizziness.However,testssuchaselectrocardiography,Holtermonitortesting,and
carotidDopplertestingshouldbeperformedonlyifanunderlyingcardiaccauseissuspectedbasedonotherfindingsorknowncardiacdisease.7

AdditionalTesting
Ingeneral,laboratorytestingandradiographyarenotbeneficialintheworkupofpatientswithdizzinesswhennootherneurologicabnormalitiesarepresent.31,32
Laboratorystudies,includingcompletebloodcount,metabolicpanels,andthyroidfunctiontests,haveverylowyieldindiagnosingacauseofdizziness.Inone
metaanalysis,only26of4,538patients(0.6percent)hadlaboratoryabnormalitiesthatexplainedtheirdizziness.7

Electronystagmographytestsvestibularfunctionbyusingelectrodestodetectnystagmus.Thetesthasareportedsensitivityof69to74percentandspecificityof
81to83percentforperipheralvestibulardisorders.Forcentralvestibulardisorders,sensitivityhasbeenreportedashighas81percentandspecificityashighas
93percent.7

ApproachtothePatient
Afterobtainingthepatienthistory,thephysiciancantailorthephysicalexaminationtobestfitthedifferentialdiagnosis.Oneapproachtotheinitialevaluationof
patientswithdizzinessispresentedinFigure2.

View/PrintFigure

ApproachtothePatientwithDizziness

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 12.05.2017 Dzzness:ADagnostcApproachAmercanFamlyPhyscan

Figure2.

Algorithmfortheinitialevaluationofapatientwithdizziness.

Theinitialhistorycanhelpplacethediagnosisintooneofthefourmajorcategoriesofdizziness.Then,questionsspecifictothatcategorycanfurthernarrowthe
possiblediagnoses.Athoroughneurologicandcardiovascularexaminationshouldbeperformedinallpatients,aswellastargetedcomponentsofthephysical
examinationbasedonsuspicionoftheunderlyingdiagnosis.Furthertesting,suchascardiacandradiologictesting,isonlyneededwhenspecificcausesare
suspected.

Treatmentofvertigohasbeenaddressed.33Table4summarizesthetreatmentofselectedcausesofdizziness,10,18,3449andFigure3illustratestheEpley
maneuver,aneffectivetreatmentforBPPV.41

View/PrintTable

Table4.
TreatmentforSelectedCausesofDizziness
CAUSE TREATMENT COMMENTS

Vertigo

Benign Meclizine(Antivert),25to50mgorally Commonlyusedtoreducesymptomsofacuteepisodesofvertigo,althoughtherearenoRCTstosupport

paroxysmal everyfourtosixhours itsuseuseofvestibularsuppressantscanleadtobrainstemcompensationandprolongvertiginous
positional symptoms
vertigo
Epleymaneuver(canalithrepositioning Mainbenignparoxysmalpositionalvertigotreatmentsafeandeffectivecomparedwithplacebovideo
seeFigure3) demonstrationisavailableathttp://www.youtube.com/watch?v=ZqokxZRbJfw&ampNR=1
(http://www.youtube.com/watch?v=ZqokxZRbJfw&NR=1)

Vestibularrehabilitation Seriesofheadandneckexercisesthatcanbeperformeddailyathomevideodemonstrationavailableat
http://www.youtube.com/watch?v=hhinu_oU_hM(http://www.youtube.com/watch?v=hhinu_oU_hM)

Evidenceforbalancetherapy(e.g.,taichi,WiiFit)isaccumulating

Meniere Saltrestriction(lessthan1to2gof NolargescaleRCTstosupportthesetherapies

disease sodiumperday)and/ordiuretics(most
commonly,
hydrochlorothiazide/triamterene
[Dyazide])

Intratympanicdexamethasoneor Referraltoanotolaryngologistrequiredinonesmallstudy,dexamethasoneresolvedsymptomsin82
gentamicin percentofpatientsinalargerstudy,gentamicinresolvedsymptomsin80.7percentofpatients46,47

Endolymphaticsacsurgery Referraltoanotolaryngologistrequired

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View/PrintFigure

Figure3.

Epleymaneuver(canalithrepositioning).Thetechniqueinvolvesaseriesofmovements.(A)Themaneuverbeginswiththepatientsittingwiththeheadrotated45degreestotheright.
(B)Thephysicianlaysthepatientintoasupinepositionwiththeheadhangingovertheendofthetable.(C)Theheadisthenrotated90degreestotheleft,(D)andtheheadandbody
arerotatedtogetheranadditional90degreesuntilthepatientis135degreesfromtheinitialsupineposition.(E)Thepatientisbroughttoasittingpositionwhiletheheadremains
tilted.Finally,theheadisbroughtforwardanddownwardtoanangleof20degrees.Thephysicianshouldpauseateachpositionuntilnystagmusresolves,andthewholeseries
shouldberepeateduntilnonystagmusispresentatanyposition.Themaneuvercanalsobeginwiththepatientinthesupineposition.Avideodemonstrationofthismaneuveris
availableathttp://www.youtube.com/watch?v=ZqokxZRbJfw&ampNR=1(http://www.youtube.com/watch?v=ZqokxZRbJfw&NR=1).

Informationfromreference41.

TheAuthors showallauthorinfo
ROBERTE.POST,MD,isafacultymemberwiththeVirtuaFamilyMedicineResidencyinVoorhees,N.J.Atthetimethisarticlewaswritten,hewasaninstructorin
theDepartmentofFamilyMedicineattheMedicalUniversityofSouthCarolinainCharleston....

REFERENCES showallreferences
1.SchappertSM,BurtCW.Ambulatorycarevisitstophysicianoffices,hospitaloutpatientdepartments,andemergencydepartments.VitalHealthStat.13.2006
(159):166....

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