Dizziness (Diagnostic approach)
INTRODUCTION
1.
"Dizziness" is non-specific term often used by patients to describe symptoms. The most
common disorders lumped under this term include vertigo, non-specific "dizziness",
disequilibrium, and presyncope. The first and most important step in the evaluation is to fit
the patient into one of these more specific categories.
2. The general approach to dizziness is reviewed here. The evaluation of vertigo and presyncope
(the evaluation of which is the same as syncope evaluation) are discussed in detail separately.
GENERAL APPROACH
1. The reported proportion of patients with various etiologies of dizziness in community survey,
primary care setting, ED, and specialized dizzy clinic are remarkably similar.
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A. 40% have peripheral vestibular dysfunction
B. 10% have central brainstem vestibular lesion
C. 15% have psychiatric disorder
D. 25% have other problems, such as presyncope and disequilibrium
E. 10% remains uncertain in approximately.
The distribution of causes varies with age. The elderly have higher incidence of central
vestibular causes of vertigo (approaching 20%), most often due to stroke. Psychiatric
conditions and presyncope account for more dizziness in younger individuals.
The patient's description is critical for establishing etiology of dizziness. In one series,
history was most sensitive for identifying vertigo (87%), presyncope (74%), psychiatric
disorders (55%), and disequilibrium (33%). PE generally confirmed but did not make diagnosis.
Positional changes in symptoms, orthostatic BP and pulse changes, observation of gait, and
detection of nystagmus were most helpful on PE. Most psychiatric disorders were not
detected prior to standardized psychological testing using diagnostic interview schedule (DIS).
Not surprisingly, no patients volunteered likelihood of psychiatric cause of dizziness.
Asking open-ended questions, listening to patient's description of his or her symptoms, and
checking and gathering additional information from specific questions should allow clinician
to form hypothesis regarding type of dizziness. As example, patient who says "I nearly blacked
out" might be asked "Do you mean you nearly fainted?" An affirmative reply elicits another
checking question, "So you felt you were passing out?" Checking hypothesis by placing
symptom into context, including its time course, provoking and aggravating factors,
concurrent symptoms, age, pre-existing condition and findings on PE will narrow differential,
and allow clinician to decide on need for further testing and/or evaluation.
In addition, physician's hypothesis must be checked against features of other causes of
dizziness. When physician suspects patient is suffering from vertigo, he or she may ask, "So
you say it was spinning sensation, did you feel at all as though you were also going to pass out
or faint?" Careful listening and checking generally leads to right hypothesis. It is important to
do this initially so that evaluation will proceed down correct pathway.
VERTIGO
1. Vertigo is predominant symptom that arises from acute asymmetry of vestibular system. The
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vestibular system includes vestibular apparatus in inner ear, vestibular nerve and nucleus
within medulla, as well as connections to and from vestibular portions of cerebellum. Vertigo
is discussed in more detail separately.
Patients often experience vertigo as illusion of motion; some interpret these as self-motion,
others as motion of environment. The most common perception is spinning sensation;
patients may also use terms such as "whirling," "tilting," or "moving." However, not all
patients describe their vertigo in such vivid terms. Vague dizziness, imbalance, or
disorientation may eventually prove to be due to vestibular problem.
Distinguishing vertigo from other types of dizziness
A.
B.
C.
The spinning quality of vertiginous sensations is notoriously unreliable. Lack of spinning
cannot be used to exclude vestibular disease, given difficulty many patients have in
putting their dizzy experience into words. On the other hand, some patients with
presyncope from vasovagal or cardiac disease can interpret their sensation of dizziness
as spinning sensation.
Time course, provoking factor, and aggravating factor of dizziness are more useful
features in establishing cause of dizziness. One study found that many physicians that
evaluate patients with dizziness may rely too heavily on symptom quality for diagnosis
and do not appreciate clinical significance of these other features.
Time course
i.
Vertigo is never continuous for more than few weeks. Even when vestibular lesion
is permanent, CNS adapts to defect so that vertigo subsides over several weeks.
Constant dizziness lasting months are usually psychogenic, not vestibular. However,
physician must be clear on what patient means by "constant." Some patients who
say they have constant dizziness for months actually mean that they have constant
susceptibility to frequent episodic dizziness; this can be vestibular problem.
D. Provoking factor
i.
Certain types of vertigo occur spontaneously, while others are precipitated by
maneuvers that change head position or middle ear pressure (coughing, sneezing,
or Valsalva maneuvers). Positional vertigo and postural presyncope are two
common conditions that are frequently confused. Both are associated with dizziness
upon standing, as when arising from bed. The key to diagnosis is to determine
whether dizziness can be provoked by maneuvers that change head position
without lowering BP or decreasing cerebral blood flow. Such maneuvers include
lying down, rolling over, and bending neck back to look up. Dizziness in these
settings suggests positional vertigo, not postural presyncope.
E.
4.
Aggravating factor
i.
All vertigo is made worse by moving head. This is useful feature for distinguishing
vertigo from other forms of dizziness. Many patients in midst of vertiginous attack
are petrified to move. If head motion does not worsen feeling, it is probably
another type of dizziness.
Associated signs and symptoms
A. Vertigo whether of central or peripheral origin is generally accompanied by nystagmus
and postural instability. Other signs and symptoms may be useful in distinguishing
between central and peripheral causes of vertigo.
B. Nystagmus
i.
The presence of nystagmus suggests that dizziness is vertigo. Nystagmus is not
ii.
always readily visible, although more subtle forms can be seen during funduscopy
or on electronystagmography. Some types of nystagmus are only seen after
provocative maneuver (Dix-Hallpike maneuver). The bilaterally symmetric
appearance of few beats of horizontal nystagmus on lateral gaze is normal
(physiologic ‘endpoint’ nystagmus). Pathologic nystagmus is asymmetric or more
pronounced or prolonged.
Certain features of nystagmus may suggest central vs. peripheral cause of vertigo.
Clinical distinction between central and peripheral vertigo
Peripheral
Central
Nystagmus
Direction
Type
Unidirectional, fast component toward
Sometimes reverses direction when patient
normal ear; never reverses direction
looks in direction of slow component
Horizontal with torsional component, never
Can be any direction
purely torsional or vertical
Visual fixation
Suppressed
Not suppressed
Neurologic sign
Absent
Often present
Postural instability
Unidirectional instability, walking preserved
Severe instability, patient often falls
Hearing problem
May be present
Absent
iii.
Positional changes such as flexing, extending, rotating, or laterally bending cervical
spine may elicit vertigo and nystagmus in susceptible patients.
1. Barany or Dix-Hallpike maneuver involves moving patient rapidly from sitting
to lying position with head tilted downward off table at 45 degrees and
rotated 45 degrees to one side. This is key diagnostic test for BPPV, and has
80% sensitivity for this specific condition. It should be stressed that maneuver
is NOT useful in diagnosing other vestibulopathies.
2. The supine roll test for lateral semicircular canal-related vertigo may be
performed in patients with compatible history but negative Dix-Hallpike
maneuver.
iv.
The onset of vertigo and nystagmus with these maneuvers establishes vertigo as
patient's symptom, if vertiginous sensation is same as patient previously
experienced. The examiner notes features of symptoms and signs to aid in
distinction between central and peripheral causes of vertigo.
C. Postural instability
i.
The effects of lesions of vestibular system upon postural stability are variable, but it
is common for patients with vertigo to have difficulty maintaining steady upright
posture when walking, standing, and even sitting unsupported, particularly when
symptoms are acute.
D. Hearing loss
i.
Symptoms of ear involvement are very suggestive of peripheral vertigo, although
their absence does not exclude diagnosis. The physician should ask if there has
been any hearing loss, its duration and progression, whether unilateral or bilateral,
and accompanying symptoms such as discharge, tinnitus, or history of otitis.
ii.
Subclinical hearing loss can be detected with reasonable sensitivity in office by
holding your fingers few inches away from patient's ear and rubbing them together
softly or asking patient to repeat few numbers or words whispered into his or her
ear. 512-Hz tuning fork is also useful. Audiometry is more sensitive.
E. Brainstem sign
i.
The presence of additional neurologic signs strongly suggests presence of central
vertigo. Symptoms such as staggering or ataxic gait, vomiting, headache, double
ii.
vision, visual loss, slurred speech, weakness, clumsiness, or incoordination should
be reviewed with patient.
A careful NE should be performed for cranial nerve abnormality, Horner syndrome,
motor or sensory changes, dysmetria, or abnormal reflexes. However, absence of
other neurologic findings does not entirely exclude central process.
PRESYNCOPE
1. Presyncope is prodromal symptom of fainting or near faint. Presyncope occurs more
commonly than syncope. It usually lasts for seconds to minutes and is often recognized by
patient as "nearly blacking out" or "nearly fainting." When symptoms are less intense, their
description may be less clear. Patients may also report lightheadedness, feeling of warmth,
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diaphoresis, nausea, and visual blurring occasionally proceeding to blindness. An observation
of pallor by onlookers usually indicates presyncope. Presyncope usually occurs when patient is
standing or seated upright and not when supine (if latter, one should suspect arrhythmia
rather than HoTN).
A history of cardiac disease, including dysrhythmias, CAD, CHF, is relevant. The patient should
be asked specifically about palpitations, chest discomfort, or dyspnea (although this may
suggest anxiety as alternative cause as well).
The etiology and evaluation of presyncope are same as for syncope. Orthostatic HoTN,
arrhythmia, and vasovagal attack are some of more common causes.
DISEQUILIBRIUM
1. Disequilibrium is sense of imbalance that occurs primarily when walking. Chronic dizziness
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or disequilibrium can cause significant impairment of physical and social functioning,
particularly in the elderly.
Disequilibrium may result from peripheral neuropathy, musculoskeletal disorder interfering
with gait, vestibular disorder, cerebellar disorder, and/or cervical spondylosis. Patients with
Parkinson disease frequently suffer from disequilibrium and are subject to postural HoTN as
well as imbalance. Cervical spondylosis may be associated with dizziness that is apparently
related to disturbance in postural control, although this is not universally accepted cause of
dizziness. Visual impairment, whether from underlying eye disease or poor lighting, typically
exacerbates sense of imbalance. This is also true of cerebellar disorders. Cerebellar disorders
can affect mainly gait, but often have associated dysarthria and eye signs, such as
gaze-evoked nystagmus, poor smooth pursuit, and downbeat nystagmus. If cerebellar
hemisphere is also involved, there will be incoordination of limbs.
3. The physician should inquire about symptoms of neurologic and gait disorders, especially
those suggestive of Parkinsonism, cerebellar incoordination, or peripheral neuropathy. In the
series cited above, few patients volunteered that their dizziness was associated with walking,
standing, turning, or falling; most with disequilibrium required observation of gait and
neurologic examination to identify the diagnosis.
NONSPECIFIC DIZZINESS
1. Nonspecific dizziness is often difficult for patient to describe. He or she may simply insist, "I
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am dizzy." Patients may choose from suggested descriptions to say they are "giddy" or
"lightheaded"; however, they may also endorse fainting or spinning sensation.
Psychiatric disorders may be the primary cause of nonspecific dizziness in some cases. 25%
of such individuals had major depression, 25% had generalized anxiety or panic disorder, and
remainder had somatization disorder, alcohol dependence, and/or personality disorder in 1
series. Other series report higher rates of panic disorder. Ill-defined disorders such as
fibromyalgia have also been associated with dizziness and vertigo. Patients who have chief
cause of dizziness that is not psychiatric may also have psychiatric disorder as contributing
factor. Psychotherapy may help manage this type of dizziness. A meta-analysis of 3 RCT that
used CBT in combination with relaxation techniques or vestibular rehabilitation found that
therapy was helpful in managing dizziness in the short term, although not associated anxiety
and depression.
Nonspecific dizziness is commonly related to hyperventilation. Dizziness that accompanies
hyperventilation, anxiety, or depression often builds up gradually, waxes and wanes over a
period of 20 minutes or longer and gradually resolves. There may be no sensation of "air
hunger" since these patients are hyperventilating only to slight degree. This usually occurs in
settings that are at least mildly stressful.
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Less intense versions of presyncope or vertigo may be experienced by patient as nonspecific
dizziness. Nonspecific dizziness (as well as vertigo) may follow head trauma or whiplash
injuries. Hypoglycemic episodes may also produce a nonspecific sensation of dizziness as the
chief symptom. In addition, patients should be asked about medications, especially
antidepressants and anti-cholinergics; a variety of medications produce dizziness as a side
effect or as a symptom of abrupt drug withdrawal.
There are no physical signs that are diagnostic of nonspecific dizziness. Most patients are
healthy, young individuals without detectable disease involving neurologic, CV, or
otolaryngologic systems. Purposeful hyperventilation is one means to confirm that diagnosis.
The patient is coached to hyperventilate until he or she becomes dizzy, then to identify
whether or not the dizziness mimics spontaneously occurring symptoms. If so, the patient will
be convinced, as well as the physician, that hyperventilation is the etiology. However, the
examiner must observe the eyes of the patient to see if there is nystagmus; some pathologic
vestibular lesions are exacerbated or unmasked by hyperventilation. If nystagmus is seen, the
diagnosis is vestibular lesion, not hyperventilation.
Reproducing symptoms by hyperventilation is often reassuring to the patient and in itself
therapeutic. It is possible for individuals to learn to breathe less deeply and through the nose,
thereby limiting hyperventilation. If patients understand that number of minutes must elapse
before symptoms resolve, they can spontaneously abort their own attacks. Treatment of
anxiety or depression with pharmacotherapy should be based upon the symptoms of these
disorders, not necessarily upon the presence of nonspecific dizziness.
DIZZINESS IN OLDER PATIENTS
1. Dizziness in the older adult deserves specific mention because of its high prevalence, up to
38% in some series, and its attendant risk of falls, functional disability, institutionalization, and
even death. Assessment of dizziness in older patients is challenging because it is frequently
attributable to multiple problems, including vertigo, CV disease, neck disorders, physical
deconditioning, and medications. Visual impairment from cataracts and other conditions is
common in older adults and likely exacerbates the disability that is associated with dizziness.
One study found that 44% of patients aged 65 to 95 years had > 1 condition causing dizziness.
Some call this entity multiple-sensory defect dizziness.
2. In a population-based study of 1087 community living individuals 72 years of age or older, 261
(24%) reported having an episode of dizziness during the two months prior to study onset and
that the dizziness (whether persistent or intermittent) had been present for at least 1 month.
The investigators found seven characteristics that were independently associated with
dizziness on multivariate analysis
A. Anxiety trait
B. Depressive symptoms
C. Impaired balance (path deviation and time to turn circle > 4 seconds)
D. Past myocardial infarction
E. Postural hypotension (mean decrease in blood pressure ≥ 20%)
F.
G.
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4.
≥ 5 medications
Impaired hearing
Only 10% of study participants with none of these seven characteristics reported dizziness.
Prevalence of dizziness in those who had 1, 2, 3, 4, and ≥ 5 of these characteristics was 18, 27,
33, 50, and 68%. The authors concluded that while dizziness in some older individuals may
primarily be due to one problem, a number of older patients likely have a multifactorial
etiology.
One study of 417 patients aged 65 to 95 years found that most of patients had
presyncope-type dizziness. Underlying CV disease was the most common contributing factor
in 57%, followed by peripheral vestibulopathies (14%), and psychiatric conditions (10%).
Drug side effects were a minor contributor in 25% of patients.
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Treatment in these individuals should be directed at the most remediable problems.
Physicians should also ask about falling or dizziness while driving, which would require
intervention to prevent injury.
SUMMARY
1. The cause of dizziness (vertigo, presyncope, disequilibrium, or nonspecific dizziness) is best
elucidated by the history and confirmed by physical examination.
2. Most patients with dizziness have vertigo. Most patients experience vertigo as an illusion of
movement, not necessarily spinning, of themselves or the environment. A key historical
aspect of vertigo is exacerbation by head movement.
3. The presence of nystagmus suggests that the dizziness is vertigo. Associated hearing loss or
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tinnitus suggests peripheral vertigo; associated brainstem signs suggest central vertigo.
Presyncope is usually experienced as a sensation of impending faint. This diagnosis is
suggested by the occurrence of dizziness only in the upright posture, in patients with cardiac
disease, and when associated pallor is described by onlookers.
Dizziness that represents disequilibrium or a sense of imbalance may be presenting symptom
of a peripheral neuropathy, parkinsonism, cerebellar disease, and/or cervical myelopathy.
Nonspecific dizziness is ill described and has a wide differential diagnosis that may include
milder forms of vertigo, presyncope, and disequilibrium, as well as medication side effects,
psychiatric disease, and metabolic derangements.
Older patients often have multiple etiologic contributors to their dizziness.