Applied Evidence

Standardizing your approach to dizziness and vertigo

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First, determine whether the sensation the patient is experiencing is dizziness or true vertigo. Then eliminate ominous causes from the array of benign ones.


› 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



Dizziness. Vertigo. These 2 terms are often used interchangeably by patients, with the sensations described as imbalance, lightheadedness, disorientation, presyncope, confusion—among others. While dizziness is a broad term that is often used to describe all the aforementioned sensations, including vertigo, true vertigo (a specific type of dizziness) is defined as the perception of movement within one’s visual field while stationary.1 Because patients are not usually aware of the distinction, their reports of signs and symptoms can cause much confusion for health care providers, thereby delaying a diagnosis.

International studies have reported the prevalence of both dizziness and vertigo to be between 15% and 36%.2,3 Over half of all patients with dizziness and vertigo are cared for by the family physician (FP), and the sensations combined account for approximately 5% of all family medicine visits.4,5 Additionally, between 2.5% and 4% of all emergency department (ED) visits stem from complaints of dizziness and vertigo, with an incidence of up to 25% in those >65 years of age.6,7

Causes of dizziness and vertigo are broad, ranging from the benign to the life-threatening. It has been reported that upwards of 50% of patients presenting to the FP’s office for dizziness leave without a diagnosis.8 Given the confusion surrounding the terms and their broad differential, this review aims to provide FPs with the tools to accurately discern benign from ominous causes.

Nonvestibular benign causes vastly outnumber life-threatening ones

Causes of dizziness are classified as either vestibular (these cause true vertigo) or nonvestibular in origin, with nonvestibular causes being more common.7

Nonvestibular etiologies: Numerous and varied

Nonvestibular causes are broad, spanning many different body systems. Cardiovascular causes of dizziness may include orthostatic hypotension, cardiac arrhythmia, myocardial infarction, and carotid artery stenosis.4,9 Metabolic causes include complications of diabetes such as hypoglycemia and peripheral neuropathy.4,9 Psychiatric conditions such as anxiety, depression, and bipolar disorder can manifest as dizziness, disorientation, or psychogenic vertigo.4,10 Medications including nonsteroidal anti-inflammatory drugs, anticonvulsants, antipsychotics, and sedatives can all contribute to dizziness.11 Other causes of dizziness include Parkinson’s disease, musculoskeletal disorders, and gait disorders.4,9 Especially in the elderly, sensory deficit (peripheral neuropathy), poor vision, and polypharmacy (≥5 medications) are common causes of dizziness.12

Vestibular etiologies of dizziness = true vertigo

Vestibular causes of a patient’s feelings of dizziness manifest as true vertigo and can be categorized as either central (a dysfunction of one or more parts of the central nervous system that help process balance and spatial information or along the pathway where these sensations are interpreted) or peripheral (a dysfunction of the balance organs of the inner ear) in origin.

Central vestibular causes include vertebrobasilar ischemic stroke, vertebrobasilar insufficiency (transient ischemic attack), vestibular migraines, and meningioma of the cerebellopontine angle and posterior fossa.13

Continue to: Peripheral vestibular causes


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