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Emergency and Acute Medicine – Dizziness
Basics
Description
Patient descriptions of dizziness (vertigo, lightheadedness, disequilibrium, or nonspecific terms) are often unreliable and should not guide decision making. A safer approach emphasizes associated symptoms, timing, and triggers, followed by a focused physical examination for diagnostic clues. Dizziness is categorized using a “timing and triggers” framework. Acute vestibular syndrome presents with abrupt onset of persistent dizziness. Episodic vestibular syndrome consists of spontaneous episodes lasting minutes to hours. Positional vestibular syndrome causes very brief episodes, typically 20–50 seconds, triggered by head or body position changes. Chronic vestibular syndrome has a gradual onset and persists for weeks to months or longer.
Etiology
General medical causes account for nearly half of cases and include arrhythmias, hypoglycemia and other metabolic disturbances, hypovolemia, sepsis, infections, and low cardiac output states. Otologic or vestibular causes represent about one third and include benign paroxysmal positional vertigo, labyrinthitis, and vestibular neuritis. Neurologic causes include stroke, transient ischemic attack, and vestibular migraine. Psychiatric causes such as anxiety and depression account for a smaller proportion.
Diagnosis
Signs and symptoms
History should define the timing and trigger pattern and assess for red flags. Key questions address onset, persistence versus intermittence, duration of episodes, positional triggers, associated hearing or neurologic symptoms, recent head injury, and new medications. Review of systems should focus on clues to serious disease, including headache suggesting stroke or dissection, ear pain suggesting otitis or mastoiditis, hearing changes suggesting Ménière disease or labyrinthitis, neck pain suggesting vertebral dissection, fever suggesting infection, dyspnea suggesting pulmonary embolism or anemia, chest pain suggesting acute coronary syndrome, fluid losses suggesting hypovolemia, and pregnancy-related complications.
Exacerbation with head motion occurs in both central and peripheral causes; however, dizziness only with head motion in an otherwise asymptomatic patient suggests a peripheral etiology.
Physical examination
Vital signs are assessed, including orthostatic testing. Otoscopic examination, cardiac examination, and a complete neurologic examination are essential. Cranial nerves II–XII should be evaluated with special attention to nystagmus. Gait observation and cerebellar testing are performed. The Dix–Hallpike maneuver is reserved for intermittent symptoms.
The HINTS examination is used only in patients with acute vestibular syndrome and consists of head impulse testing, nystagmus assessment, and testing for skew deviation. In the first 48 hours of symptoms, this exam can be more sensitive than MRI for detecting stroke. A normal head impulse test without corrective saccade suggests a central cause, whereas a corrective saccade suggests a peripheral cause. Direction-changing, vertical, or torsional nystagmus suggests a central etiology, while direction-fixed nystagmus suggests a peripheral cause. A vertical corrective saccade on alternate cover testing indicates a central process. Any concerning component should prompt concern for stroke.
Essential workup
History and physical examination are mandatory and often sufficient. Triage focuses on abnormal vital signs, altered mentation, or focal deficits. The evaluation is guided by timing, triggers, and telltale signs such as HINTS findings in acute dizziness.
Diagnosis tests and interpretation
Laboratory testing may include serum glucose, hematocrit if anemia is suspected, electrolytes, renal function tests, venous blood gas when carbon monoxide or hypercapnia is considered, urinalysis for infection, and toxicology screening when exposure is suspected.
Imaging includes noncontrast head CT when acute hemorrhage is suspected, recognizing limited sensitivity for posterior circulation ischemia. MRI is indicated when no alternative etiology is found and the HINTS exam is concerning.
Diagnostic procedures may include Dix–Hallpike testing, head thrust testing, and skew deviation assessment. Electrocardiography is used to detect arrhythmia or myocardial ischemia. Lumbar puncture is considered for unexplained headache or infectious signs.
Differential diagnosis
Acute vestibular syndrome includes benign causes such as vestibular neuritis and labyrinthitis and dangerous causes such as cerebellar or brainstem stroke. Episodic vestibular syndrome includes vestibular migraine and transient ischemic attack. Positional vestibular syndrome includes benign paroxysmal positional vertigo and, rarely, central paroxysmal positional vertigo from posterior fossa mass. Chronic vestibular syndrome includes psychiatric causes, medication effects, and rarely posterior fossa tumors.
Treatment
Initial stabilization and therapy
Stabilization is directed by abnormal vital signs or associated systemic illness. Management depends on classification of dizziness and suspected etiology.
Emergency department treatment and procedures
Symptomatic control is provided while evaluation proceeds. If benign paroxysmal positional vertigo is suspected, the Epley maneuver should be performed.
Medication
Symptomatic medications include ondansetron, diazepam, diphenhydramine, meclizine for short-term use only, and promethazine. Response to these agents does not establish etiology.
Follow-up and disposition
Admission criteria
Admission decisions depend on the underlying cause and associated symptoms, particularly concern for stroke, cardiac disease, or systemic illness.
Discharge criteria
Patients with isolated dizziness, normal neurologic and oculomotor examinations, and ability to function safely at home may be discharged with instructions.
Issues for referral
Outpatient referral may be to primary care, otolaryngology, or neurology depending on the suspected cause.
Follow-up recommendations
Patients should avoid driving or operating machinery while symptomatic and rise slowly from sitting or lying positions. They should seek immediate care for new neurologic deficits, signs of infection, acute cardiopulmonary symptoms, or significant fluid losses.
Pearls and pitfalls
The timing-and-triggers approach improves diagnostic accuracy. Advanced age and vascular risk factors increase stroke likelihood. Noncontrast CT is insensitive for acute cerebellar stroke, and cerebellar infarction may present with isolated dizziness. A negative head impulse test is concerning for central pathology. The treatment for benign paroxysmal positional vertigo is the Epley maneuver, not vestibular suppressants.
Basics
Description
Patient descriptions of dizziness (vertigo, lightheadedness, disequilibrium, or nonspecific terms) are often unreliable and should not guide decision making. A safer approach emphasizes associated symptoms, timing, and triggers, followed by a focused physical examination for diagnostic clues. Dizziness is categorized using a “timing and triggers” framework. Acute vestibular syndrome presents with abrupt onset of persistent dizziness. Episodic vestibular syndrome consists of spontaneous episodes lasting minutes to hours. Positional vestibular syndrome causes very brief episodes, typically 20–50 seconds, triggered by head or body position changes. Chronic vestibular syndrome has a gradual onset and persists for weeks to months or longer.
Etiology
General medical causes account for nearly half of cases and include arrhythmias, hypoglycemia and other metabolic disturbances, hypovolemia, sepsis, infections, and low cardiac output states. Otologic or vestibular causes represent about one third and include benign paroxysmal positional vertigo, labyrinthitis, and vestibular neuritis. Neurologic causes include stroke, transient ischemic attack, and vestibular migraine. Psychiatric causes such as anxiety and depression account for a smaller proportion.
Diagnosis
Signs and symptoms
History should define the timing and trigger pattern and assess for red flags. Key questions address onset, persistence versus intermittence, duration of episodes, positional triggers, associated hearing or neurologic symptoms, recent head injury, and new medications. Review of systems should focus on clues to serious disease, including headache suggesting stroke or dissection, ear pain suggesting otitis or mastoiditis, hearing changes suggesting Ménière disease or labyrinthitis, neck pain suggesting vertebral dissection, fever suggesting infection, dyspnea suggesting pulmonary embolism or anemia, chest pain suggesting acute coronary syndrome, fluid losses suggesting hypovolemia, and pregnancy-related complications.
Exacerbation with head motion occurs in both central and peripheral causes; however, dizziness only with head motion in an otherwise asymptomatic patient suggests a peripheral etiology.
Physical examination
Vital signs are assessed, including orthostatic testing. Otoscopic examination, cardiac examination, and a complete neurologic examination are essential. Cranial nerves II–XII should be evaluated with special attention to nystagmus. Gait observation and cerebellar testing are performed. The Dix–Hallpike maneuver is reserved for intermittent symptoms.
The HINTS examination is used only in patients with acute vestibular syndrome and consists of head impulse testing, nystagmus assessment, and testing for skew deviation. In the first 48 hours of symptoms, this exam can be more sensitive than MRI for detecting stroke. A normal head impulse test without corrective saccade suggests a central cause, whereas a corrective saccade suggests a peripheral cause. Direction-changing, vertical, or torsional nystagmus suggests a central etiology, while direction-fixed nystagmus suggests a peripheral cause. A vertical corrective saccade on alternate cover testing indicates a central process. Any concerning component should prompt concern for stroke.
Essential workup
History and physical examination are mandatory and often sufficient. Triage focuses on abnormal vital signs, altered mentation, or focal deficits. The evaluation is guided by timing, triggers, and telltale signs such as HINTS findings in acute dizziness.
Diagnosis tests and interpretation
Laboratory testing may include serum glucose, hematocrit if anemia is suspected, electrolytes, renal function tests, venous blood gas when carbon monoxide or hypercapnia is considered, urinalysis for infection, and toxicology screening when exposure is suspected.
Imaging includes noncontrast head CT when acute hemorrhage is suspected, recognizing limited sensitivity for posterior circulation ischemia. MRI is indicated when no alternative etiology is found and the HINTS exam is concerning.
Diagnostic procedures may include Dix–Hallpike testing, head thrust testing, and skew deviation assessment. Electrocardiography is used to detect arrhythmia or myocardial ischemia. Lumbar puncture is considered for unexplained headache or infectious signs.
Differential diagnosis
Acute vestibular syndrome includes benign causes such as vestibular neuritis and labyrinthitis and dangerous causes such as cerebellar or brainstem stroke. Episodic vestibular syndrome includes vestibular migraine and transient ischemic attack. Positional vestibular syndrome includes benign paroxysmal positional vertigo and, rarely, central paroxysmal positional vertigo from posterior fossa mass. Chronic vestibular syndrome includes psychiatric causes, medication effects, and rarely posterior fossa tumors.
Treatment
Initial stabilization and therapy
Stabilization is directed by abnormal vital signs or associated systemic illness. Management depends on classification of dizziness and suspected etiology.
Emergency department treatment and procedures
Symptomatic control is provided while evaluation proceeds. If benign paroxysmal positional vertigo is suspected, the Epley maneuver should be performed.
Medication
Symptomatic medications include ondansetron, diazepam, diphenhydramine, meclizine for short-term use only, and promethazine. Response to these agents does not establish etiology.
Follow-up and disposition
Admission criteria
Admission decisions depend on the underlying cause and associated symptoms, particularly concern for stroke, cardiac disease, or systemic illness.
Discharge criteria
Patients with isolated dizziness, normal neurologic and oculomotor examinations, and ability to function safely at home may be discharged with instructions.
Issues for referral
Outpatient referral may be to primary care, otolaryngology, or neurology depending on the suspected cause.
Follow-up recommendations
Patients should avoid driving or operating machinery while symptomatic and rise slowly from sitting or lying positions. They should seek immediate care for new neurologic deficits, signs of infection, acute cardiopulmonary symptoms, or significant fluid losses.
Pearls and pitfalls
The timing-and-triggers approach improves diagnostic accuracy. Advanced age and vascular risk factors increase stroke likelihood. Noncontrast CT is insensitive for acute cerebellar stroke, and cerebellar infarction may present with isolated dizziness. A negative head impulse test is concerning for central pathology. The treatment for benign paroxysmal positional vertigo is the Epley maneuver, not vestibular suppressants.
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