The American Academy of Family Physicians recommends using a systematic approach based on timing, triggers, and targeted examination (TiTrATE mnemonic) to evaluate dizziness, as patient descriptions of symptoms are often unreliable for establishing a diagnosis.
History and Classification
The initial assessment should focus on timing (episodic vs. acute vestibular syndrome) and triggers (triggered vs. spontaneous) rather than traditional symptom quality categories. Episodic vestibular syndrome refers to recurrent episodes lasting seconds to hours, while acute vestibular syndrome involves continuous symptoms lasting days to weeks. The following diagnostic algorithm illustrates this systematic approach:
For patients with triggered episodic vestibular syndrome, perform the Dix-Hallpike maneuver and orthostatic vital signs. Orthostatic hypotension is defined as a sustained reduction in systolic blood pressure of at least 20 mm Hg or diastolic blood pressure reduction of 10 mm Hg within three minutes of standing. Transient upbeat-torsional nystagmus during the Dix-Hallpike maneuver suggests benign paroxysmal positional vertigo, especially in the absence of spontaneous or gaze-evoked nystagmus.
For patients with spontaneous acute vestibular syndrome concerning for central etiology, perform a full neurologic examination and the HINTS (head-impulse, nystagmus, test of skew) examination. When performed by trained clinicians, the HINTS examination has 97% sensitivity and 96% specificity for identifying central causes such as acute stroke.
Laboratory Testing and Imaging
Most patients presenting with dizziness do not require laboratory testing. Routine imaging is not indicated for peripheral causes, but consider CT of the temporal bone or MRI of the head and internal auditory canal for patients with hearing loss or aural fullness. If central causes are suspected (neoplasms, Chiari malformations, demyelinating lesions), consider MRI of the head and internal auditory canal with and without contrast.
The differential diagnosis includes peripheral and central causes. Common peripheral etiologies include benign paroxysmal positional vertigo, vestibular neuritis, and Meniere disease. Central etiologies include vestibular migraine and vertebrobasilar ischemia. Other causes encompass cardiac conditions (acute coronary syndrome, arrhythmia), metabolic disorders, and psychiatric conditions.
Treatment depends on the underlying etiology. For benign paroxysmal positional vertigo, canalith repositioning procedures (e.g., Epley maneuver) are most effective, with a success rate approaching 100%. Vestibular rehabilitation is safe and effective, with best long-term outcomes achieved through combination of vestibular rehabilitation and repositioning maneuvers. Pharmacologic treatments including antihistamines and benzodiazepines are generally not indicated as they interfere with central compensation and increase fall risk. In patients with vitamin D deficiency, replacement may lower recurrence rates.
The differential diagnosis of dizziness is broad, affecting approximately 5% of primary care visits. Roughly half of emergency department patients with dizziness have general medical conditions, 33% have peripheral vestibular causes, and 11% have neurological etiologies (of which one-third are cerebrovascular). Only 3.2-6% of ED patients with acute dizziness have serious central causes, mostly ischemic stroke.
Key Diagnostic Considerations
When evaluating dizziness, it is important to avoid anchoring bias and consider general medical conditions that may present with dizziness. Co-chief complaints such as dizziness plus dyspnea, chest pain, fever, or new medications should prompt evaluation for specific diagnoses. Vital sign abnormalities including fever, significant tachycardia or bradycardia, irregular pulse, hypoxia, or hypotension should always be explained.
Vestibular symptoms may be characterized as "isolated" when the only associated symptoms are nonlocalizing ones that routinely accompany vestibular pathology (malaise, nausea, vomiting, nystagmus, postural instability). The presence of new focal neurological symptoms (lateralizing weakness, numbness, dysarthria, diplopia, limb ataxia) would make the syndrome "nonisolated" and raise concern for central pathology.
Additional Management Considerations
For Meniere disease, treatment includes salt restriction and diuretics. Vestibular neuritis symptoms are relieved with vestibular suppressant medications and vestibular rehabilitation. Orthostatic hypotension causing presyncope can be treated with alpha agonists, mineralocorticoids, or lifestyle changes. A final diagnosis is not obtained in approximately 20% of cases.
