Dizziness is common in internal medicine patients, accounting for up to 5% of visits to primary care clinics, according to a paper in the August 15, 2010, American Family Physician. Yet because patients use the terms “dizziness” and “vertigo” to describe a broad range of sensations, the symptom can pose a diagnostic challenge.
“‘Dizziness' is an ambiguous term, so the first thing to do is clarify what patients are talking about by asking them to describe what they're feeling,” said Yolanda Reyes-Iglesias, MD, assistant professor of clinical neurology and chief of the neurology department at the Miami VA Healthcare System and director for undergraduate medical education at the University of Miami's Miller School of Medicine. “Then, based upon their description, you can tell if they are talking about light-headedness, vertigo, near syncope, or gait problems.”
When patients say they're dizzy, they're usually describing one of four conditions, said Martin Samuels, MD, MACP, chair of the department of neurology at Brigham and Women's Hospital and Miriam Sydney Joseph Professor of Neurology at Harvard Medical School in Boston. Dr. Samuels breaks it down this way:
- true vertigo, in which there is a feeling of motion when there is no motion;
- near syncope, in which there is a sensation just short of fainting, to include lightheadedness;
- disequilibrium, which is more a gait or stance disorder in which patients describe feeling unstable on their feet or like they're about to fall, and
- anxiety, in which patients use the term “dizzy” to describe feelings of fear, worry, or anxiousness.
“Most patients have one, and many have two of the four, but it's rare to have a full house of all of them,” Dr. Samuels said.
From there, physicians can delve deeper into symptoms, said Dr. Reyes-Iglesias. “Think about symptoms that could be associated with either the ear or the brain. Is there hearing loss or ringing or buzzing in the ear? Are there problems with vision, balance, or weakness? Did symptoms start acutely and are getting better, have they built up slowly over time, or do they fluctuate? Are there associated headaches?”
Make sure it's not stroke
The most important task primary care physicians have in working up patients who report “dizziness” is to rule out stroke, and keeping the patient's age and comorbidities in mind can help, said Douglas Paauw, MD, MACP, professor in the department of internal medicine and director of internal medicine medical student programs at the University of Washington in Seattle.
“I look at vertigo based on patient age, what is likely to occur, and what you don't want to miss. Recurrent dizziness for 5 minutes at a time in a 20-year-old could mean a variant of migraine. But if the patient is 80 years old, the symptoms could point to blood flow problems related to ischemia,” said Dr. Paauw. “The most scary causes of vertigo are the vascular causes we see in the elderly because they can signify the start of stroke syndrome. These patients will usually have other risk factors as well, such as hypertension, diabetes, and past smoking.”
Dr. Reyes-Iglesias agreed. “Do a careful history and exam. Isolated vertigo is rare in stroke. The patient will have risk factors for stroke, and there are usually other symptoms such as gait issues, focal weakness, and clumsiness.”
It's a reassuring sign when the patient feels very ill, Dr. Reyes-Iglesias added. “The sicker the patient is with the vertigo, the less worried I am. If there is distressing nausea and vomiting, it's usually a problem in the ear. But the less nausea and vomiting there is, the more I'm worried because then I start thinking about the brain.”
If a patient has what Dr. Samuels called “true vertigo,” the sensation of movement when there is no motion, he suggested the three-part oculomotor head impulse, nystagmus, and test-of-skew (HINTS) method as a quick way to rule out stroke. Outlined in the Nov. 1, 2009, Stroke, the HINTS method has been shown to be an effective way of differentiating brainstem or cerebellar strokes from acute peripheral vestibulopathy caused by a virus.
“Once you determine your patient is not experiencing symptoms of stroke, then you're left with common disorders: problems in the ear, issues with sensation in the lower extremities, or anxiety,” said Dr. Samuels.
According to a consensus statement of the Committee for the Classification of Vestibular Disorders of the Bárány Society published in the Journal of Vestibular Research in 2015, one of the most common forms of vertigo is benign paroxysmal positional vertigo (BPPV), in which calcium carbonate crystals that normally reside in the utricle of the ear are dislodged and end up in the semicircular canals. The paper noted that about 10% of the general population experiences BPPV at least once in life.
“It's super common in any age group but especially common in the elderly,” said Dr. Paauw, adding that it's fairly easy to diagnose. “The history is incredibly specific. Movement causes a violent spinning sensation that lasts 30 seconds or so and then goes away rapidly. It usually happens when the patient is lying down and turns over.”
In addition to vertigo that is provoked by lying down or turning over and a short duration of attacks, the Bárány Society's consensus statement lists positional nystagmus prompted by the Dix-Hallpike maneuver among its diagnostic criteria. The maneuver involves positioning a seated patient's head 30 to 45 degrees toward one side and, while supporting the patient's head, having the patient lie back quickly so his or her head hangs off the exam table. If the patient experiences vertigo or nystagmus, the patient most likely has BPPV. The test can also help determine which ear is affected.
If there is hearing loss, ask questions to determine if the patient has Ménière's disease, said Dr. Paauw. “The patient will have a combination of vertigo, hearing loss, ringing in the ears or tinnitus, and a feeling of fullness in the ear.”
Michael Teixido, MD, associate chief of otolaryngology at the Christiana Care Health System in Wilmington, Del., pointed out that vestibular migraine has emerged as another common cause of vertigo and dizziness, occurring in up to half of patients who seek treatment for vertigo.
“Vestibular migraine is 15 to 20 times more common than Ménière's disease. The work-up is obvious when the patient has a headache at the same time as the vertigo, but many patients don't have concurrent headaches,” said Dr. Teixido. “There may instead have been an increase in headache activity in the prior 3 months, and the dizziness may act like a migraine in that it responds to typical migraine triggers like stress, fatigue, changes in the weather, hormonal changes, caffeine, or foods like chocolate or red wine.”
Vestibular migraine and BPPV are often related, Dr. Teixido added. “When we see BPPV in patients younger than 60, most either have had some kind of head injury like an airbag deployment that knocked the crystals loose or they have migraine. Patients who have migraine headaches are about 5 times as likely to get BPPV. We think this is because changes in the blood vessels may actually injure the inner ear and allow the crystals to become loose.”
Orthostatic hypotension is another common cause of vertigo and dizziness and plays into presyncope, said Dr. Samuels. “Check the blood pressure while the patient is standing, sitting, or lying down. Also round up the usual suspects: medications [that could be interacting or incorrectly dosed] and volume depletion. Consider whether the patient may have heart disease.”
A general unsteadiness may point to issues with sensation, said Dr. Samuels. He suggests the Romberg test as the go-to method of assessment. “Have the patient stand at attention, look in the distance, and then close his or her eyes. If the patient is unbalanced with the eyes closed, that means something is wrong with sensation from the lower extremities.”
Dr. Samuels added that if there are signs of trouble with sensation, the next step is to determine if the problem is peripheral, such as diabetic neuropathy, or in the spinal cord or brain. “Check the tendon reflexes. If the reflexes are depressed in the legs, it's probably a peripheral problem. If not, look for Babinksi's sign: Scratch the bottom of the foot, and if the big toe goes up, not down, it almost always means there's a central nervous system problem.”
When patients use terms like “dizziness” and “vertigo” as a metaphor for anxiety, the physician may pick up on the condition in the exam room, Dr. Samuels said. “It actually makes you anxious as an examiner, so if you find yourself becoming anxious, look into the patient's history for depression or primary anxiety disorders.”
When to refer
While it's obvious that signs of stroke require an immediate ED visit, patients should also be referred to the ED if symptoms of vertigo or dizziness are new, severe, and acute, said Dr. Teixido. “If the patient doesn't have any previous, trusted pattern of dysfunction, the vertigo is brand new for them, and they have associated cardiovascular risk like heart disease, vasculopathy, or uncontrolled hypertension, or they're on blood thinners, they should be sent to the ED.”
Referral to otolaryngologists, neurologists, or cardiologists will depend on what the primary care physician suspects is causing the vertigo or dizziness. But primary care physicians can and should attempt to treat more benign conditions like migraine and BPPV, said Dr. Teixido.
“BPPV is so common that internists need to know how to treat it, and then send the hard cases that don't respond to treatment to an ENT,” Dr. Teixido said. “There are plenty of YouTube videos demonstrating the diagnostic Dix-Hallpike maneuver and the exercises used to move the crystals back into place when their location is known. Generic Brandt-Daroff exercises are helpful for patients even if the involved ear and canal are not known so primary care physicians can confidently show patients how to do the exercises themselves. “
Likewise, referral is necessary if the suspected cause is viral and the patient doesn't respond to treatment, said Dr. Samuels. “If the patient doesn't follow the natural history you expect and is still having symptoms after a three-week course of medication, there are new symptoms, or symptoms get worse, that would require a referral to a neurologist. If there is hearing loss, the patient needs to see an ENT.”