Standardizing your approach to dizziness and vertigo

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Standardizing your approach to dizziness and vertigo

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

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

References

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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