Approach to dizziness and vertigo: Clinical sciences

Dizziness is a term used to describe symptoms such as loss of balance, lightheadedness, and altered spatial orientation, while vertigo refers to an abnormal sensation of self-motion or movement of the surrounding environment. Now, dizziness can occur because of metabolic, cardiac, and neurologic conditions, while vertigo typically occurs due to vestibular or focal brain conditions.

Now, if your patient presents with dizziness or vertigo, the first step is to obtain a focused history and physical examination and establish which of these they are experiencing.

First, let’s focus on dizziness! In this case, your patient will describe lightheadedness, altered orientation of space, or feeling faint. There will be no abnormal sensation of motion, but the patient might report feeling off-balance. In some cases, history might reveal nausea and vomiting, while the physical exam might demonstrate some degree of gait impairment and no nystagmus!

With these findings, diagnose dizziness, so be sure to assess the timing of symptoms, which could be episodic or persistent. Let’s first take a look at episodic dizziness.

If the dizziness is episodic, further assess the underlying cause with additional history and exam evaluation. Some common causes include orthostatic hypotension and panic disorder. First, let's discuss orthostatic hypotension...

Orthostatic hypotension is typically associated with dizziness when moving to an upright position, such as with sitting or standing up. The patient may feel their heart racing, or that they are about to pass out with a darkening of their vision. There might be a recent history of volume depletion, such as from vomiting, diarrhea, or blood loss. Additionally, history might reveal neurologic conditions causing autonomic dysfunction, such as Parkinson disease, multiple system atrophy, and neuropathy.

The physical exam involves checking blood pressure in supine and standing positions. After standing up, the systolic blood pressure will drop at least 20 mmHg, or the diastolic blood pressure will drop at least 10 mmHg. Additionally, you might notice a prolonged capillary refill time or pallor on exam. With these findings, diagnose orthostatic hypotension.

Now, here's a clinical pearl to keep in mind! In addition to orthostatic hypotension, other conditions that can cause dizziness due to transient hypoperfusion of the brain include cardiac conditions, such as arrhythmias, aortic stenosis, and heart failure.

Let’s now talk about panic disorder, which is associated with intense episodes of fear or discomfort that peak within minutes, known as panic attacks. The patient might also report shortness of breath or chest pain. Additionally, the physical exam will reveal tachycardia, sometimes in combination with diaphoresis and tremulousness. With these findings, diagnose panic disorder. Now, switching gears and moving on to persistent dizziness.

If the dizziness is persistent, further assess the underlying cause with additional history and exam evaluation. First, let’s focus on the medication side effects! Most commonly, your patient will be elderly and report symptoms that have started with the initiation of a new medication or an increase in medication dosage. This is especially common with antihypertensive and antihistamine medications. The physical exam is typically normal, but sometimes it might reveal bradycardia or hypotension. In this case, the probable cause of dizziness is a medication side effect. So, if possible, discontinue the medication, and if the dizziness resolves, you can be sure of the diagnosis!

Finally, let’s discuss post-concussion syndrome. In this case, your patient will report that the dizziness started after head trauma! Additionally, they might report headaches, sleep disturbance, mood changes, and trouble with attention or memory. Depending on the severity of the brain injury, the physical exam might reveal abnormal cognitive testing or a focal neurologic deficit. With these findings, diagnose post-concussion syndrome.

Now, let’s go back and take a look at individuals with vertigo! In this case, your patient will describe an abnormal sensation of motion, such as spinning, tilting, or sinking. Often, your patient will report that they are feeling off-balance, and, in some cases, they might report nausea and vomiting. The physical exam may demonstrate gait impairment or nystagmus. With these findings, you can diagnose vertigo, so your next step is to assess the timing of vertigo!

If vertigo is episodic, assess the underlying cause and consider two common conditions, which include benign paroxysmal positional vertigo, or BPPV for short, and Ménière disease.

First, let’s discuss BPPV, which occurs due to the dislodgement of calcium carbonate crystals from the utricle into the semicircular canals, most commonly the posterior canal.
Your patient will describe recurrent episodes of vertigo that last only seconds and occur when they change the head position. Some examples include when sitting up in bed or lying down. Since the condition is limited to the vestibular organs, there will be no hearing loss or tinnitus.

During the physical exam, you should perform a Dix-Hallpike test. To perform the Dix-Hallpike test, have your patient sit. Next, slightly extend their neck, turn it to one side, and rapidly place them in a supine position, so that their head hangs over the edge of the bed. Keep your patient in this position for 30 seconds. If the head is turned towards the affected ear, the patient will report vertigo, and you will see nystagmus that is upbeating and torsional in the direction of the affected ear. These findings are consistent with posterior canal involvement, meaning the Dix-Hallpike test is positive.

With these findings, diagnose BPPV. If there’s no nystagmus or vertigo, return the individual to the upright position and wait for another 30 seconds. After that, repeat the maneuver for the other side as well.

Here’s a clinical pearl to keep in mind! Once you diagnose BPPV, perform the Epley maneuver, which repositions the calcium carbonate crystals from the semicircular canals and helps relieve vertigo symptoms!

Alright, let’s switch gears and move on to Ménière disease, which is typically associated with recurrent episodes lasting minutes to hours with no apparent triggers. The patient will describe hearing loss, possibly tinnitus, and a sensation of ear pressure or fullness. These symptoms are thought to be due to an increase in endolymphatic fluid in the inner ear. The physical exam will be notable for a negative Dix-Hallpike test. In this case, diagnose Ménière disease.