Dizziness

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

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

• Vestibular/otologic
  • Benign paroxysmal positional vertigo (BPPV)
  • Traumatic (following head injury)
  • Infection
    • Labyrinthitis
    • Vestibular neuritis
    • Ramsay Hunt syndrome
  • Ménière's disease
  • Ear foreign body
  • Otic barotrauma
  • Otosclerosis
• Neurologic
  • Cerebellar stroke
  • Vertebrobasilar insufficiency
  • Lateral Wallenberg syndrome
  • Anterior inferior cerebellar artery syndrome
  • Neoplastic: cerebellopontine angle tumors
  • Basal ganglion diseases
  • Vertebral Artery Dissection
  • Multiple sclerosis
  • Infections: neurosyphilis, tuberculosis
  • Epilepsy
  • Migraine (basilar)
• Other
  • Hematologic: anemia, polycythemia, hyperviscosity syndrome
  • Toxic
    • Alcohol
    • Aminoglycosides
  • Chronic renal failure
  • Metabolic
    • Thyroid Disease
    • Hypoglycemia

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)

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)
• 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

External Links

• ALiEM: HINTS Exam