A New Diagnostic Approach to the Adult Patient with Acute Dizziness

Abstract

Background: Dizziness, a common chief complaint, has an extensive differential diagnosis that includes both benign and serious conditions. Emergency physicians must distinguish the majority of patients with self-limiting conditions from those with serious illnesses that require acute treatment.

Objective of the review: This article presents a new approach to diagnosis of the acutely dizzy patient that emphasizes different aspects of the history to guide a focused physical examination with the goal of differentiating benign peripheral vestibular conditions from dangerous posterior circulation strokes in the emergency department.

Discussion: Currently, misdiagnoses are frequent and diagnostic testing costs are high. This relates in part to use of an outdated, prevalent, diagnostic paradigm. The traditional approach, which relies on dizziness symptom quality or type (i.e., vertigo, presyncope, or disequilibrium) to guide inquiry, does not distinguish benign from dangerous causes, and is inconsistent with current best evidence. A new approach divides patients into three key categories using timing and triggers, guiding a differential diagnosis and targeted bedside examination protocol: 1) acute vestibular syndrome, where bedside physical examination differentiates vestibular neuritis from stroke; 2) spontaneous episodic vestibular syndrome, where associated symptoms help differentiate vestibular migraine from transient ischemic attack; and 3) triggered episodic vestibular syndrome, where the Dix-Hallpike and supine roll test help differentiate benign paroxysmal positional vertigo from posterior fossa structural lesions.

Conclusions: The timing and triggers diagnostic approach for the acutely dizzy patient derives from current best evidence and offers the potential to reduce misdiagnosis while simultaneously decreases diagnostic test overuse, unnecessary hospitalization, and incorrect treatments.

Keywords: BPPV; diagnosis; dizziness; misdiagnosis; nystagmus; posterior circulation stroke; vertigo; vestibular neuritis.

Figure 1

Diagnostic approach to the acutely dizzy patient. ATTEST = A, associated symptoms; TT, timing and triggers; ES, examination signs; and T, additional testing as needed. The first step is to take a history focused on associated symptoms, timing and triggers of the dizziness, and the overall context. Many patients’ histories will suggest a general medical cause (various toxic, metabolic, infectious, or cardiovascular causes). In this group of patients, we recommend a very brief diagnostic “stop” in order to reduce misdiagnosis. As part of this stop, first make sure there are no suspicious neurovestibular signs (nystagmus, limb ataxia, or gait/truncal ataxia). If a general medical cause still seems likely, evaluate and treat for the presumed diagnosis or diagnoses. For patients with a positive stop or whose history does not suggest a general medical cause, ask questions aimed at timing and triggers to place the patient into one of three categories. For patients in the acute vestibular syndrome (AVS) and triggered, episodic vestibular syndrome (t-EVS), physical examination (see text) will often allow a specific diagnosis to be made. For patients with the spontaneous episodic vestibular syndrome (s-EVS), use history to try to distinguish vestibular migraine from transient ischemic attack (TIA) or other causes (see text) since, by definition, these patients will no longer have symptoms and their dizziness cannot be triggered at the bedside. BPPV = benign paroxysmal positional vertigo.