Dizziness: Difference between revisions

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(Comprehensive expansion of Dizziness page with EM-focused approach: TiTrATE framework, HINTS exam, BPPV evaluation, and structured DDx/management)
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==Background==
*Dizziness is one of the most common chief complaints in the ED, accounting for approximately 4% of ED visits
*The term "dizziness" is nonspecific and can refer to several distinct sensations:
**'''Vertigo''' — sensation of movement (room spinning or self-spinning); suggests vestibular pathology
**'''Presyncope/lightheadedness''' — feeling of impending faint; suggests cardiovascular or systemic cause
**'''Disequilibrium''' — sense of unsteadiness or imbalance; suggests neurologic or musculoskeletal cause
**'''Nonspecific dizziness''' — vague lightheadedness, often multifactorial (medications, metabolic, psychiatric)
*The traditional approach of categorizing dizziness by "type" has limitations; a '''timing and triggers''' approach is recommended<ref>Newman-Toker DE, Edlow JA. TiTrATE: A Novel, Evidence-Based Approach to Diagnosing Acute Dizziness and Vertigo. Neurol Clin. 2015;33(3):577-599.</ref>
==Clinical Features==
*History is the most important tool — focus on timing, triggers, and associated symptoms
*Key questions:
**'''Timing:''' Episodic (seconds, minutes, hours) vs continuous (days-weeks)?
**'''Triggers:''' Positional? Spontaneous? With head movement?
**'''Associated symptoms:''' Hearing loss, tinnitus, headache, diplopia, dysarthria, dysphagia, focal weakness, chest pain, palpitations?
*Red flags suggesting central (dangerous) cause:
**Acute onset with inability to walk
**New headache (especially occipital/posterior)
**Any focal neurologic deficit (diplopia, dysarthria, dysphagia, ataxia, weakness, numbness)
**Direction-changing nystagmus or pure vertical/torsional nystagmus
**Truncal ataxia (unable to sit upright)
**Neck pain (consider [[vertebral artery dissection]])
**New cardiac symptoms (chest pain, dyspnea, palpitations)
==Differential Diagnosis==
===By Timing (TiTrATE Approach)===
====Triggered Episodic Vestibular Syndrome (seconds, triggered by position)====
*[[Benign paroxysmal positional vertigo]] (BPPV) — most common cause
*[[Orthostatic hypotension]]
*Superior canal dehiscence
*Central positional vertigo (rare)
====Spontaneous Episodic Vestibular Syndrome (minutes to hours, spontaneous)====
*[[Vestibular migraine]]
*[[Ménière's disease]]
*[[TIA]] (vertebrobasilar)
*[[Arrhythmia]] / cardiac syncope
*Panic attack / [[anxiety]]
====Acute Vestibular Syndrome (continuous >24 hours)====
*'''Dangerous:''' [[Cerebellar stroke]] or brainstem stroke (most important to rule out)
*'''Benign:''' [[Vestibular neuritis]] / [[Labyrinthitis]]
*[[Multiple sclerosis]]
*Medication toxicity (aminoglycosides, anticonvulsants)
====Chronic Vestibular Syndrome====
*Persistent postural-perceptual dizziness (PPPD)
*Bilateral vestibular hypofunction
*Neurodegeneration
===Non-Vestibular Causes===
*[[Orthostatic hypotension]] / volume depletion
*[[Anemia]]
*[[Hypoglycemia]]
*Medication side effect (antihypertensives, sedatives, anticonvulsants, ototoxic drugs)
*Cardiac ([[arrhythmia]], [[aortic stenosis]], [[heart failure]])
*Psychiatric ([[anxiety]], [[panic disorder]], hyperventilation)
*[[Carbon monoxide toxicity]]
{{Vertigo DDX}}
==Evaluation==
==Evaluation==
*<24 hours (transient episodes)
===Workup===
**Diagnose by "triggers"
*[[Finger stick glucose]]
***See [[Vertigo]]
*Orthostatic vital signs
***See [[Syncope]]
*[[ECG]] — if cardiac cause suspected
*24hrs - 72 hrs (Acute Vestibular Syndrome)
*Consider CBC, BMP, troponin based on clinical suspicion
**See [[Vertigo#HINTS Exam|HINTS Exam]]
*'''CT head is low yield''' for isolated dizziness without neurologic deficits
*'''MRI/MRA''' — if central cause suspected (note: CT misses >80% of posterior fossa strokes within first 24-48 hours)<ref>Chalela JA, Kidwell CS, Nentwich LM, et al. Magnetic resonance imaging and computed tomography in emergency assessment of patients with suspected acute stroke: a prospective comparison. Lancet. 2007;369(9558):293-298.</ref>
 
===Key Exam Maneuvers===
====[[HINTS Exam]] (for Acute Vestibular Syndrome)====
*'''H'''ead '''I'''mpulse (normal = central), '''N'''ystagmus (direction-changing = central), '''T'''est of '''S'''kew (positive = central)
*If ALL three suggest peripheral → [[vestibular neuritis]] likely (sensitivity >96% for stroke detection, superior to early MRI)<ref>Kattah JC, Talkad AV, Wang DZ, Hsieh YH, Newman-Toker DE. HINTS to diagnose stroke in the acute vestibular syndrome: three-step bedside oculomotor examination more sensitive than early MRI diffusion-weighted imaging. Stroke. 2009;40(11):3504-3510.</ref>
*'''Only valid in acute vestibular syndrome''' (constant dizziness >24 hours with nystagmus)
*Do NOT use HINTS for episodic dizziness
 
====[[Dix-Hallpike test]] (for Episodic Positional Dizziness)====
*Positive test: upbeating and torsional nystagmus with latency (2-20 seconds) and fatigability
*Diagnostic for posterior canal [[BPPV]]
 
====Supine Roll Test====
*For suspected horizontal canal BPPV
 
==Management==
===Acute Vestibular Syndrome===
*If central cause suspected (abnormal HINTS) → emergent neuroimaging (MRI preferred) and [[stroke]] workup
*If peripheral ([[vestibular neuritis]]):
**Symptomatic management with vestibular suppressants (use sparingly, short-term only)
**[[Meclizine]] 25 mg PO q6-8h PRN
**[[Dimenhydrinate]] 50 mg PO/IV q6h PRN
**[[Ondansetron]] for nausea
**Encourage early vestibular rehabilitation and ambulation
 
===BPPV===
*[[Epley maneuver]] (canalith repositioning) — 80% effective in single treatment
*Avoid meclizine as chronic therapy for BPPV (delays central compensation)
 
===Presyncope/Orthostatic===
*IV fluids for volume depletion
*Address underlying cause (medication adjustment, cardiac workup)
 
===General===
*Treat underlying cause
*Avoid vestibular suppressants long-term as they impair central compensation
 
==Disposition==
*'''Admit:'''
**Suspected central cause (stroke, vertebral artery dissection)
**Unable to ambulate safely
**Persistent vomiting with inability to tolerate PO
**Significant cardiac cause identified
*'''Discharge with follow-up:'''
**BPPV after successful Epley maneuver
**Vestibular neuritis with improvement and ability to ambulate
**Peripheral cause with adequate symptom control
**Arrange ENT or neurology follow-up as appropriate
 
==See Also==
*[[Vertigo]]
*[[Syncope]]
*[[BPPV]]
*[[Vestibular neuritis]]
*[[Labyrinthitis]]
*[[Cerebellar stroke]]
*[[HINTS Exam]]
*[[Dix-Hallpike test]]
*[[Epley maneuver]]


==Videos==
==External Links==
{{#widget:YouTube|id= G8rYqrQFCLk}}
*[https://www.aliem.com/trick-of-trade-hints-exam/ ALiEM: HINTS Exam]
{{#widget:YouTube|id= ymzYaCmepd0}}


==References==
==References==
Tarnutzer AA, et al. "Does my dizzy patient have a stroke? A systematic review
<references/>
of bedside diagnosis in acute vestibular syndrome" CMAJ 2011


[[Category:Neurology]]
[[Category:Neurology]]
[[Category:ENT]]
[[Category:Symptoms]]

Revision as of 22:53, 20 March 2026

Background

  • Dizziness is one of the most common chief complaints in the ED, accounting for approximately 4% of ED visits
  • The term "dizziness" is nonspecific and can refer to several distinct sensations:
    • Vertigo — sensation of movement (room spinning or self-spinning); suggests vestibular pathology
    • Presyncope/lightheadedness — feeling of impending faint; suggests cardiovascular or systemic cause
    • Disequilibrium — sense of unsteadiness or imbalance; suggests neurologic or musculoskeletal cause
    • Nonspecific dizziness — vague lightheadedness, often multifactorial (medications, metabolic, psychiatric)
  • The traditional approach of categorizing dizziness by "type" has limitations; a timing and triggers approach is recommended[1]

Clinical Features

  • History is the most important tool — focus on timing, triggers, and associated symptoms
  • Key questions:
    • Timing: Episodic (seconds, minutes, hours) vs continuous (days-weeks)?
    • Triggers: Positional? Spontaneous? With head movement?
    • Associated symptoms: Hearing loss, tinnitus, headache, diplopia, dysarthria, dysphagia, focal weakness, chest pain, palpitations?
  • Red flags suggesting central (dangerous) cause:
    • Acute onset with inability to walk
    • New headache (especially occipital/posterior)
    • Any focal neurologic deficit (diplopia, dysarthria, dysphagia, ataxia, weakness, numbness)
    • Direction-changing nystagmus or pure vertical/torsional nystagmus
    • Truncal ataxia (unable to sit upright)
    • Neck pain (consider vertebral artery dissection)
    • New cardiac symptoms (chest pain, dyspnea, palpitations)

Differential Diagnosis

By Timing (TiTrATE Approach)

Triggered Episodic Vestibular Syndrome (seconds, triggered by position)

Spontaneous Episodic Vestibular Syndrome (minutes to hours, spontaneous)

Acute Vestibular Syndrome (continuous >24 hours)

Chronic Vestibular Syndrome

  • Persistent postural-perceptual dizziness (PPPD)
  • Bilateral vestibular hypofunction
  • Neurodegeneration

Non-Vestibular Causes

Vertigo

Evaluation

Workup

  • Finger stick glucose
  • Orthostatic vital signs
  • ECG — if cardiac cause suspected
  • Consider CBC, BMP, troponin based on clinical suspicion
  • CT head is low yield for isolated dizziness without neurologic deficits
  • MRI/MRA — if central cause suspected (note: CT misses >80% of posterior fossa strokes within first 24-48 hours)[2]

Key Exam Maneuvers

HINTS Exam (for Acute Vestibular Syndrome)

  • Head Impulse (normal = central), Nystagmus (direction-changing = central), Test of Skew (positive = central)
  • If ALL three suggest peripheral → vestibular neuritis likely (sensitivity >96% for stroke detection, superior to early MRI)[3]
  • Only valid in acute vestibular syndrome (constant dizziness >24 hours with nystagmus)
  • Do NOT use HINTS for episodic dizziness

Dix-Hallpike test (for Episodic Positional Dizziness)

  • Positive test: upbeating and torsional nystagmus with latency (2-20 seconds) and fatigability
  • Diagnostic for posterior canal BPPV

Supine Roll Test

  • For suspected horizontal canal BPPV

Management

Acute Vestibular Syndrome

  • If central cause suspected (abnormal HINTS) → emergent neuroimaging (MRI preferred) and stroke workup
  • If peripheral (vestibular neuritis):
    • Symptomatic management with vestibular suppressants (use sparingly, short-term only)
    • Meclizine 25 mg PO q6-8h PRN
    • Dimenhydrinate 50 mg PO/IV q6h PRN
    • Ondansetron for nausea
    • Encourage early vestibular rehabilitation and ambulation

BPPV

  • Epley maneuver (canalith repositioning) — 80% effective in single treatment
  • Avoid meclizine as chronic therapy for BPPV (delays central compensation)

Presyncope/Orthostatic

  • IV fluids for volume depletion
  • Address underlying cause (medication adjustment, cardiac workup)

General

  • Treat underlying cause
  • Avoid vestibular suppressants long-term as they impair central compensation

Disposition

  • Admit:
    • Suspected central cause (stroke, vertebral artery dissection)
    • Unable to ambulate safely
    • Persistent vomiting with inability to tolerate PO
    • Significant cardiac cause identified
  • Discharge with follow-up:
    • BPPV after successful Epley maneuver
    • Vestibular neuritis with improvement and ability to ambulate
    • Peripheral cause with adequate symptom control
    • Arrange ENT or neurology follow-up as appropriate

See Also

External Links

References

  1. ↑ Newman-Toker DE, Edlow JA. TiTrATE: A Novel, Evidence-Based Approach to Diagnosing Acute Dizziness and Vertigo. Neurol Clin. 2015;33(3):577-599.
  2. ↑ Chalela JA, Kidwell CS, Nentwich LM, et al. Magnetic resonance imaging and computed tomography in emergency assessment of patients with suspected acute stroke: a prospective comparison. Lancet. 2007;369(9558):293-298.
  3. ↑ Kattah JC, Talkad AV, Wang DZ, Hsieh YH, Newman-Toker DE. HINTS to diagnose stroke in the acute vestibular syndrome: three-step bedside oculomotor examination more sensitive than early MRI diffusion-weighted imaging. Stroke. 2009;40(11):3504-3510.
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