Applied Evidence

Standardizing your approach to dizziness and vertigo

J Fam Pract. 2018 August;67(8):490-492,495-498

From The Journal of Family Practice | 2018;67(8):490-492,495-498.

References

1. Bisdorff A, Von Brevern M, Lempert T, et al. Classification of vestibular symptoms: towards an international classification of vestibular disorders. J Vestib Res. 2009;19:1-13.

2. Mendel B, Bergenius J, Langius-Eklöf A. Dizziness: a common, troublesome symptom but often treatable. J Vestib Res. 2010;20:391-398.

3. Gopinath B, McMahon CM, Rochtchina E, et al. Dizziness and vertigo in an older population: the Blue Mountains prospective cross‐sectional study. Clin Otolaryngol. 2009;34:552-556.

4. Post RE, Dickerson LM. Dizziness: a diagnostic approach. Am Fam Physician. 2010;82:361-368.

5. Sloan PD. Dizziness in primary care. Results from the National Ambulatory Care Survey. Fam Pract. 1989;29:33-38.

6. Kerber KA, Meurer WJ, West BT, et al. Dizziness presentations in US emergency departments, 1995–2004. Acad Emerg Med. 2008;15:744-750.

7. Newman-Toker DE, Hsieh YH, Camargo CA Jr, et al. Spectrum of dizziness visits to US emergency departments: cross-sectional analysis from a nationally representative sample. Mayo Clin Proc. 2008;83:765-775.

8. Ponka D, Kirlew M. Top 10 differential diagnoses in family medicine: vertigo and dizziness. Can Fam Physician. 2007;53:1959.

9. Chan Y. Differential diagnosis of dizziness. Curr Opin in Otolaryngol Head Neck Surg. 2009;17:200-203.

10. Staab JP, Ruckenstein MJ. Expanding the differential diagnosis of chronic dizziness. Arch Otolaryngol Head Neck Surg. 2007;133:170-176.

11. Kutz JW Jr. The dizzy patient. Med Clin North Am. 2010;94:989-1002.

12. Jahn K, Kressig RW, Bridenbaugh SA, et al. Dizziness and unstable gait in old age: etiology, diagnosis and treatment. Dtsch Ärztebl Int. 2015;112:387-393.

13. Thompson TL, Amedee R. Vertigo: a review of common peripheral and central vestibular disorders. Ochsner J. 2009;9:20-26.

14. Parnes LS, Agrawal SK, Atlas J. Diagnosis and management of benign paroxysmal positional vertigo (BPPV). CMAJ. 2003;169:681-693.

15. Newman-Toker DE, Dy FJ, Stanton VA, et al. How often is dizziness from primary cardiovascular disease true vertigo? A systematic review. J Gen Intern Med. 2008;23:2087-2094.

16. Newman-Toker DE, Edlow JA. TiTrATE: a novel, evidence-based approach to diagnosing acute dizziness and vertigo. Neurol Clin. 2015;33:577-599.

17. Shibao C, Lipsitz LA, Biaggioni I. ASH position paper: evaluation and treatment of orthostatic hypotension. J Clin Hypertens (Greenwich). 2013;15:147-153.

18. Kaufmann H. Consensus statement on the definition of orthostatic hypotension, pure autonomic failure and multiple system atrophy. Clin Auton Res. 1996;6:125-126.

19. Agarwal AK, Garg R, Ritch A, et al. Postural orthostatic tachycardia syndrome. Postgrad Med J. 2007;83:478-480.

20. Halker RB, Barrs DM, Wellik KE, et al. Establishing a diagnosis of benign paroxysmal positional vertigo through the dix-hallpike and side-lying maneuvers: a critically appraised topic. Neurologist. 2008;14:201-204.

21. Hilton MP, Pinder DK. The Epley (canalith repositioning) manoeuvre for benign paroxysmal positional vertigo. Cochrane Database Syst Rev. 2014;(12):CD003162.

22. Kattah JC, Talkad AV, Wang DZ, et al. HINTS to diagnose stroke in the acute vestibular syndrome. Stroke. 2009;40:3504-3510.

23. Hamaguchi T, Iwasa K, Okino S, et al. Carotid duplex ultrasonography during head-up tilt in patients with orthostatic hypotension. Eur Neurol. 2007;57:219-222.

24. Canadian Society of Otolaryngology - Head & Neck Surgery. Five Things Physicians and Patients Should Question [Internet]. Choosing Wisely Canada. 2016 [cited 2017 August 17]. Available at: https://choosingwiselycanada.org/wp-content/uploads/2017/02/Hospital-medicine.pdf. Accessed August 30, 2017.

25. Lee SH, Kim JS. Benign paroxysmal positional vertigo. J Clin Neurol. 2010;6:51-63.

26. Zatonski T, Temporale H, Holanowska J, et al. Current views of treatment of vertigo and dizziness. J Med Diagn Meth. 2014;2:150.

27. Wipperman J. Dizziness and vertigo. Prim Care Clin Office Pract. 2014;41:115-131

28. Murdin L, Hussain K, Schilder AG. Betahistine for symptoms of vertigo. Cochrane Database Syst Rev. 2016;(6):CD010696.

29. Han BI, Song HS, Kim JS. Vestibular rehabilitation therapy: review of indications, mechanisms, and key exercises. J Clin Neurol. 2011;7:184-196.

30. Jung JY, Kim JS, Chung PS, et al. Effect of vestibular rehabilitation on dizziness in the elderly. Am J Otolaryngol. 2009;30:295-299.

31. Semaan MT, Megerian CA. Meniere’s disease: a challenging and relentless disorder. Otolaryngol Clin North Am. 2011;44:383-403.

32. Pirker W, Katzenschlager R. Gait disorders in adults and the elderly. Wien Klin Wochenschr. 2017;129:81-95.

33. Kirby SE, Yardley L. Physical and psychological triggers for attacks in Ménière’s disease: the patient perspective. Psychother Psychosom. 2012;81:396-398.

Peripheral vestibular causes. Benign paroxysmal positional vertigo (BPPV) represents the most common peripheral diagnosis. It is caused by dislodged otoliths in the posterior semicircular canal. While the majority of BPPV cases are idiopathic in nature, up to 15% may result from previous head injury.¹⁴ Other peripheral vestibular causes include vestibular neuronitis, viral labyrinthitis, Meniere’s disease, vestibular schwannoma, perilymphatic fistula, superior semicircular canal dehiscence (SSCD), and head trauma (basilar skull fracture).¹³

Start with a history: Is it dizziness or true vertigo?

The clinical history typically guides the differential diagnosis (FIGURE). Identifying true vertigo from among other sensations helps to limit the differential because true vertigo is caused by vestibular etiologies only. True vertigo is often reported by patients as “seeing the room spin;” this stems from the perception of motion.¹ A notable exception is that patients with orthostatic hypotension will often describe spinning sensations lasting seconds to minutes when they rise from a seated or supine position.

Never depend solely, however, on patient-reported sensations, as not all patients with true vertigo report spinning, and some patients with nonvestibular causes interpret their dizziness as a spinning sensation.¹⁵ Therefore, it is important to tease out specifics about the timing, triggers, and associated symptoms in order to further delineate possible causes (TABLE).¹⁶

Make a list of current medications. Gather a comprehensive list of current medications, especially from elderly patients, because polypharmacy is a major contributor to dizziness in this population.¹² Keep in mind that elderly patients presenting with dizziness/vertigo may have multifactorial balance difficulties, which can be revealed by a detailed history.

Physical exam: May be broad or focused

Upwards of 50% of patients presenting to the FP's office for dizziness leave without a diagnosis.

Given the broad range of causes for dizziness, cardiovascular, head/neck, and neurologic examinations may be performed as part of the work-up, as the clinical history warrants. More typically, time is spent ruling out the following common causes.

Continue to: Orthostatic hypotension