Approach to the patient with dizziness
- William T Branch, Jr, MD
William T Branch, Jr, MD
- Carter Smith Senior Professor of Medicine
- Emory University School of Medicine
- Jason JS Barton, MD, PhD, FRCPC
Jason JS Barton, MD, PhD, FRCPC
- Professor and Canada Research Chair
- Medicine (Neurology), Ophthalmology, and Visual Sciences
- The University of British Columbia
- Section Editors
- Michael J Aminoff, MD, DSc
Michael J Aminoff, MD, DSc
- Editor-in-Chief — Neurology
- Section Editor — Medical Neurology
- Professor of Neurology
- University of California, San Francisco School of Medicine
- Daniel G Deschler, MD, FACS
Daniel G Deschler, MD, FACS
- Section Editor — Otorhinolaryngology
- Professor of Otology and Laryngology
- Harvard Medical School
"Dizziness" is a nonspecific term often used by patients to describe symptoms. The most common disorders lumped under this term include vertigo, nonspecific "dizziness," disequilibrium, and presyncope. The first step in the evaluation is to fit the patient with typical symptoms into one of these categories.
The general approach to dizziness is reviewed here. The evaluation of vertigo and presyncope (the evaluation of which is the same as the syncope evaluation) are discussed in detail separately. (See "Evaluation of the patient with vertigo" and "Syncope in adults: Clinical manifestations and diagnostic evaluation".)
The reported proportion of patients with various etiologies of dizziness in community surveys , primary care setting [2,3], the emergency department [4-9], and the specialized dizzy clinic [10-14] are similar: approximately 40 percent of dizzy patients have peripheral vestibular dysfunction; 10 percent have a central brainstem vestibular lesion; 15 percent have a psychiatric disorder; and 25 percent have other problems, such as presyncope and disequilibrium (table 1). The diagnosis remains uncertain in approximately 10 percent. The distribution of causes varies with age. The elderly have a higher incidence of central causes of vertigo (approaching 20 percent), most often due to stroke.
The patient's description is critical for classifying the etiology of dizziness. In one series, the history was most sensitive for identifying vertigo (87 percent), presyncope (74 percent), psychiatric disorders (55 percent), and disequilibrium (33 percent) . The physical examination generally confirmed but did not make the diagnosis. Positional changes in symptoms, orthostatic blood pressure and pulse changes, observation of gait, and detection of nystagmus were most helpful on physical examination . Most psychiatric disorders were not detected prior to standardized psychological testing using the diagnostic interview schedule (DIS). Not surprisingly, no patients volunteered the likelihood of a psychiatric cause of dizziness.
Asking open-ended questions, listening to the patient's description of his or her symptoms, and checking and gathering additional information from specific questions should allow the clinician to form a hypothesis regarding the type of dizziness. As an example, a 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?" The clinician should also establish the time course, provoking and aggravating factors, concurrent symptoms, age, pre-existing conditions, and the findings on physical examination. These factors are especially useful to narrow the differential diagnosis when the patient’s subjective description is difficult to interpret, such as symptoms characterized as “wooziness”, brief sense of motion, or imbalance. The clinician can then decide on the need and extent of further testing and/or evaluation.
- Neuhauser HK, Radtke A, von Brevern M, et al. Burden of dizziness and vertigo in the community. Arch Intern Med 2008; 168:2118.
- Kroenke K, Lucas CA, Rosenberg ML, et al. Causes of persistent dizziness. A prospective study of 100 patients in ambulatory care. Ann Intern Med 1992; 117:898.
- Sloane PD, Dallara J, Roach C, et al. Management of dizziness in primary care. J Am Board Fam Pract 1994; 7:1.
- Herr RD, Zun L, Mathews JJ. A directed approach to the dizzy patient. Ann Emerg Med 1989; 18:664.
- Alvord LS, Herr RD. ENG in the emergency room: subtest results in acutely dizzy patients. J Am Acad Audiol 1994; 5:384.
- Madlon-Kay DJ. Evaluation and outcome of the dizzy patient. J Fam Pract 1985; 21:109.
- Skiendzielewski JJ, Martyak G. The weak and dizzy patient. Ann Emerg Med 1980; 9:353.
- Newman-Toker DE, Hsieh YH, Camargo CA Jr, et al. Spectrum of dizziness visits to US emergency departments: cross-sectional analysis from a nationally representative sample. Mayo Clin Proc 2008; 83:765.
- Navi BB, Kamel H, Shah MP, et al. Rate and predictors of serious neurologic causes of dizziness in the emergency department. Mayo Clin Proc 2012; 87:1080.
- Drachman DA, Hart CW. An approach to the dizzy patient. Neurology 1972; 22:323.
- Nedzelski JM, Barber HO, McIlmoyl L. Diagnoses in a dizziness unit. J Otolaryngol 1986; 15:101.
- Sloane PD, Baloh RW. Persistent dizziness in geriatric patients. J Am Geriatr Soc 1989; 37:1031.
- Davis LE. Dizziness in elderly men. J Am Geriatr Soc 1994; 42:1184.
- Katsarkas A. Dizziness in aging: a retrospective study of 1194 cases. Otolaryngol Head Neck Surg 1994; 110:296.
- Newman-Toker DE, Cannon LM, Stofferahn ME, et al. Imprecision in patient reports of dizziness symptom quality: a cross-sectional study conducted in an acute care setting. Mayo Clin Proc 2007; 82:1329.
- Newman-Toker DE, Dy FJ, Stanton VA, et al. How often is dizziness from primary cardiovascular disease true vertigo? A systematic review. J Gen Intern Med 2008; 23:2087.
- Stanton VA, Hsieh YH, Camargo CA Jr, et al. Overreliance on symptom quality in diagnosing dizziness: results of a multicenter survey of emergency physicians. Mayo Clin Proc 2007; 82:1319.
- Kerber KA, Baloh RW. The evaluation of a patient with dizziness. Neurol Clin Pract 2011; 1:24.
- Bhattacharyya N, Baugh RF, Orvidas L, et al. Clinical practice guideline: benign paroxysmal positional vertigo. Otolaryngol Head Neck Surg 2008; 139:S47.
- Katsarkas A, Kirkham TH. Paroxysmal positional vertigo--a study of 255 cases. J Otolaryngol 1978; 7:320.
- Wood KA, Drew BJ, Scheinman MM. Frequency of disabling symptoms in supraventricular tachycardia. Am J Cardiol 1997; 79:145.
- Fielder H, Denholm SW, Lyons RA, Fielder CP. Measurement of health status in patients with vertigo. Clin Otolaryngol Allied Sci 1996; 21:124.
- Grimby A, Rosenhall U. Health-related quality of life and dizziness in old age. Gerontology 1995; 41:286.
- Hillen ME, Wagner ML, Sage JI. "Subclinical" orthostatic hypotension is associated with dizziness in elderly patients with Parkinson disease. Arch Phys Med Rehabil 1996; 77:710.
- Karlberg M, Johansson R, Magnusson M, Fransson PA. Dizziness of suspected cervical origin distinguished by posturographic assessment of human postural dynamics. J Vestib Res 1996; 6:37.
- Yardley L, Owen N, Nazareth I, Luxon L. Panic disorder with agoraphobia associated with dizziness: characteristic symptoms and psychosocial sequelae. J Nerv Ment Dis 2001; 189:321.
- Rosenhall U, Johansson G, Orndahl G. Otoneurologic and audiologic findings in fibromyalgia. Scand J Rehabil Med 1996; 28:225.
- Schmid G, Henningsen P, Dieterich M, et al. Psychotherapy in dizziness: a systematic review. J Neurol Neurosurg Psychiatry 2011; 82:601.
- Fitzgerald DC. Head trauma: hearing loss and dizziness. J Trauma 1996; 40:488.
- Jaap AJ, Jones GC, McCrimmon RJ, et al. Perceived symptoms of hypoglycaemia in elderly type 2 diabetic patients treated with insulin. Diabet Med 1998; 15:398.
- McKiernan JM, Lowe FC. Side effects of terazosin in the treatment of symptomatic benign prostatic hyperplasia. South Med J 1997; 90:509.
- Coupland NJ, Bell CJ, Potokar JP. Serotonin reuptake inhibitor withdrawal. J Clin Psychopharmacol 1996; 16:356.
- Tinetti ME, Williams CS, Gill TM. Dizziness among older adults: a possible geriatric syndrome. Ann Intern Med 2000; 132:337.
- Lin HW, Bhattacharyya N. Balance disorders in the elderly: epidemiology and functional impact. Laryngoscope 2012; 122:1858.
- Sloane PD. Evaluation and management of dizziness in the older patient. Clin Geriatr Med 1996; 12:785.
- Maarsingh OR, Dros J, Schellevis FG, et al. Causes of persistent dizziness in elderly patients in primary care. Ann Fam Med 2010; 8:196.
- GENERAL APPROACH
- Distinguishing vertigo from other types of dizziness
- - Time course
- - Provoking factors
- - Aggravating factors
- Associated signs and symptoms
- - Nystagmus
- - Postural instability
- - Hearing loss
- - Brainstem signs
- NONSPECIFIC DIZZINESS
- DIZZINESS IN OLDER PATIENTS
- INFORMATION FOR PATIENTS