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

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Orthostatic hypotension. Orthostatic vitals are recommended initially in all patients with dizziness, although these may be normal in patients with orthostatic hypotension.¹⁷ A diagnosis of orthostatic hypotension can be made with systolic blood pressure decreases of 20 mm Hg or diastolic pressure decreases of ≥10 mm Hg within 3 minutes of standing.¹⁸ An increase in heart rate >30 beats per minute after rising from a supine position may indicate autonomic disturbances such as postural orthostatic tachycardia syndrome.¹⁹ However, physical examination findings alone are insufficient to make the diagnosis of orthostatic hypotension, and determining the underlying cause of the orthostatic hypotension (dehydration, cardiac dysfunction, pure-autonomic failure, medication adverse effect) is vital.¹⁸

BPPV. Perform the Dix-Hallpike maneuver (see https://collections.lib.utah.edu/details?id=177177 for a demonstration of the maneuver) on patients presenting with dizziness with features suggestive of BPPV (eg, attacks of dizziness triggered by head movements).^20,21

As BPPV is the most common cause of vestibular dizziness, a negative Dix-Hallpike can be helpful in refining the differential diagnosis.^20,21 The maneuver begins with the patient seated, looking directly ahead. To test the left side, ask the patient to turn his/her head 45 degrees to the left. Then direct the patient to lie back, so that the patient’s head is off the edge of the examination table and hyperextended, while maintaining the same head orientation. To test the right side, repeat the procedure with the patient turning his/her head to the right.

Torsional nystagmus is necessary for a positive Dix-Hallpike, which is diagnostic for BPPV. The laterality of BPPV can be determined by paying attention to the fast phase of the torsional nystagmus; the superior pole of the eye beats toward the affected side.¹⁴ The patient may report severe dizziness or vertigo during the Dix-Hallpike, but without torsional nystagmus, the test is negative, and the patient does not have BPPV.¹⁴

Neurologic causes. Perform a complete neurologic examination in patients who clearly do not have a history of orthostatic hypotension and who have a Dix-Hallpike test that is negative or not indicated.⁴ Also perform cerebellar testing including rapid-alternating movements, a finger-to-nose test, and a heel-to-shin test. Round out the neurologic exam with an assessment of gait and a Romberg’s test (see https://www.youtube.com/watch?v=U5a4lbmwmOw for a demonstration of Romberg’s test). Romberg’s test is performed by having the patient place his/her feet together with hands at sides and eyes closed. The patient is observed for up to a minute, with a positive test denoted by a loss of balance.

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