Standardizing your approach to dizziness and vertigo
First, determine whether the sensation the patient is experiencing is dizziness or true vertigo. Then eliminate ominous causes from the array of benign ones.
PRACTICE RECOMMENDATIONS
› Employ the Dix-Hallpike maneuver to diagnose patients presenting with dizziness with features suggestive of benign paroxysmal positional vertigo (BPPV). A
› Use the head impulse, nystagmus, test of skew (HINTS) examination to differentiate between central and peripheral vestibular causes of dizziness and rule out stroke. B
› Prescribe betahistine only for patients with Meniere’s disease and not for patients with other causes of dizziness and/or vertigo. B
› Rely on antiemetics, antihistamines, and benzodiazepines to manage acute and brief episodes of vertigo, but not to treat BPPV because they blunt central compensation. C
Strength of recommendation (SOR)
A Good-quality patient-oriented evidence
B Inconsistent or limited-quality patient-oriented evidence
C Consensus, usual practice, opinion, disease-oriented evidence, case series
From The Journal of Family Practice | 2018;67(8):490-492,495-498.
Abnormal gait may indicate peripheral neuropathy, while a positive Romberg’s test suggests involvement of the proprioceptive receptors and/or their pathway.
Central/peripheral vestibular causes. The head impulse, nystagmus, test of skew (HINTS) examination can differentiate between central and peripheral vestibular causes of dizziness and rule out stroke (a central vestibular cause).22 (See https://collections.lib.utah.edu/details?id=177180 for a video demonstrating the steps involved in performing the HINTS examination.) The head impulse (HI) portion of the exam is performed by moving the patient’s head side to side, while having the patient focus on the examiner’s nose. Rapid movements of both eyes (“abnormal” HI) suggest a peripheral etiology, while no eye movement with gaze fixated on the examiner’s nose (“normal” HI) is concerning for stroke or another central cause of vertigo.22
Nystagmus is assessed by having the patient follow the examiner’s finger as it moves in a horizontal direction. Spontaneous horizontal unidirectional nystagmus suggests a peripheral cause, while vertical or torsional bidirectional (direction-changing) nystagmus points to a central cause.22
The test of skew is executed by covering and uncovering each of the patient’s eyes, while asking the patient to look ahead. Vertical deviation of the eye after uncovering suggests a central etiology, more specifically one involving the brainstem.22
Diagnostic testing/imaging has a limited, but pivotal role
There is a limited role for routine laboratory testing in patients with dizziness. However, for those patients with underlying medical conditions (eg, diabetes), which may contribute to the symptoms, routine blood work can be ordered (ie, finger-stick blood glucose test).22
Continue to: More worrisome suspicions
