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KEY POINTS
■ A history that includes the right questions can shorten the workup for dizziness and provide key clues to the diagnosis. The first steps are to determine if the patient truly has vertigo and whether it is peripheral or central.
■ The physical examination should focus on the head and neck and on the neurologic and cardiovascular systems. Tests of vestibular function are also important. Neuroimaging is valuable when a central cause of vertigo is suspected.
■ Vestibular suppressants and antiemetic drugs are first-line choices for managing acute vertigo. A combination of an antihistamine and an antiemetic is commonly prescribed.
■ Other helpful interventions include salt restriction, use of a mild diuretic, and vestibular habituation or rehabilitation. Support groups can also be helpful in letting patients know they are not alone.
One of the most frequently encountered patient complaints is vertigo or disequilibrium. Reasonably, the evaluation of this complaint often creates anxiety in the clinician because of both the seemingly endless differential diagnosis and the question as to whether the patient has true vertigo at all. This article reviews the basic components of the evaluation—a comprehensive history and physical examination—and provides additional pearls that can help to determine the diagnosis. With a thorough yet purposeful evaluation, the cause of the patient's symptoms can be uncovered and treatment options can be more efficiently utilized.
PATHOPHYSIOLOGY
Most advances in treating vestibular disorders have come from a thorough understanding of the physiology of the inner ear. The labyrinth is an inner ear neurosensory organ made up of two components: the semicircular canals used for balance and the cochlea used for hearing.1 Typically, vertigo is caused by an imbalance of sensory inputs into the two vestibular nuclei from overactivity or underactivity of either or both sides of the labyrinth.1 Any disturbance of the labyrinth, visual-vestibular interaction centers in the brain stem and cerebellum, and sensory pathways to or from the thalamus can result in vertigo.1 One of the most common types of peripheral vertigo is benign paroxysmal positional vertigo (BPPV) which is caused by displacement of calcium carbonate crystals, called otoconia, from the utricle into the semicircular canals. Typically, patients with BPPV will be able to reproduce their symptoms by lying down or moving the head because these trapped otoconia continue to move within the semicircular canals during position change (Figure 1).
EPIDEMIOLOGY
Vestibular disorders are frequently encountered not just by neuro-otologists but also by emergency department (ED) and primary care providers. According to a 2008 study, dizziness and/or vertigo had a prevalence and incidence of 22.9% and 3.1%, respectively, over a 12-month interval.2 The study revealed a male-to-female ratio of 1:2.7; and vertigo was diagnosed almost three times more frequently in the elderly based on the age groups studied (18-39 years, 40-59 years, and 60-79 years).2 These data demonstrate how important it is for generalist clinicians to understand how to evaluate vertigo.
Apart from the challenge it presents to clinicians, vertigo also has an enormous impact on the lives of those afflicted. Compared with nonvestibular dizziness, vestibular vertigo was more frequently followed by medical consultation, sick leave, interruption of daily activities, and avoidance of leaving the house.2 Additionally, vestibular vertigo accounted for 29% of the dizziness/vertigo complaints seen by a physician.2 Interestingly, although 70% of vertigo sufferers consulted a physician, more than half the participants with clear-cut vestibular vertigo received a diagnosis of a nonvestibular disorder, often leading to a costly workup.2
THE CHALLENGES OF VERTIGO
Although understanding vertigo from a personal and epidemiologic perspective is important, clinicians also should understand the difficulties associated with evaluating this complaint. Vertiginous patients often have trouble detailing their symptoms, and some hesitate to describe exactly what they experience for fear of being perceived as foolish. Furthermore, clinicians, especially in the ED, are consumed with ruling out central causes of dizziness, which can lead to overuse of imaging and avoidance of necessary first steps in formulating a diagnosis. Another issue is the negative connotation associated with the complaint of vertigo. Providers tend to couple the complaint with lengthy histories and physical examinations, thereby leading to unnecessary referral to specialists.
Providers have an obligation to guide patients toward giving an accurate history, which in turn greatly helps the diagnostic process. A study conducted at the Mayo Clinic assessed patients' description of the quality of dizziness using four types of questions: open-ended, multi-response, single-choice, and directed.3 The researchers found that open-ended descriptions were frequently vague and that of 218 patients who did not identify vertigo, spinning, or motion on the first three questions, 70% confirmed spinning or motion sensation on directed questioning. The authors deemed that descriptions of dizziness are unclear and inconsistent and concluded that alternative approaches that emphasize timing and triggers should be further explored. Furthermore, they suggested that clinicians should rely less strictly on symptom quality to direct diagnosis and more on timing and triggers. The description of symptom quality is often misleading and can lead to inaccuracies.3
HISTORY AND EXAMINATION
Clinicians are frequently told that the history alone can often lead to an accurate diagnosis, and this is especially true when evaluating a dizzy patient. A history that includes the right questions can shorten the evaluation, as it provides key clues to the diagnosis (Figure 2).
The first step in the history is to define vertigo and then determine if the patient truly has it. Vertigo is an illusion or hallucination of movement, usually rotational, either of oneself or the environment.4 In a prospective cohort study, Hanley and O'Dowd determined if their subjects had true vertigo by asking, "When you have dizzy spells, do you feel light-headed or do you see the world spin around you?"4 This question is commonly used and is easily understood by patients. Patients who see the world spin around them have true vertigo. The duration of symptoms can also provide important clues, as detailed in Table 1.
The next step is to distinguish peripheral from central vertigo. Peripheral vertigo usually has a more sudden onset and is associated with a rotational sensation.5 Patients often have mild to moderate imbalance, can have nausea and vomiting, and usually experience auditory symptoms such as hearing loss and tinnitus. Central vertigo tends to persist for a longer period of time (hours to weeks). Often the imbalance inhibits the patient from walking or standing still, and auditory complaints are rare5 (Table 2).
