Dizziness: Approach to Evaluation and Management

Dizziness is a common yet imprecise symptom. It was traditionally divided into four categories based on the patient’s history: vertigo, presyncope, disequilibrium, and light-headedness. However, the distinction between these symptoms is of limited clinical usefulness | American family Physician


Patients have difficulty describing the quality of their symptoms but can more consistently identify the timing and triggers. Episodic vertigo triggered by head motion may be due to benign paroxysmal positional vertigo. Vertigo with unilateral hearing loss suggests Meniere disease. Episodic vertigo not associated with any trigger may be a symptom of vestibular neuritis. Evaluation focuses on determining whether the etiology is peripheral or central. Peripheral etiologies are usually benign. Central etiologies often require urgent treatment. The HINTS (head-impulse, nystagmus, test of skew) examination can help distinguish peripheral from central etiologies. The physical examination includes orthostatic blood pressure measurement, a full cardiac and neurologic examination, assessment for nystagmus, and the Dix-Hallpike maneuver. Laboratory testing and imaging are not required and are usually not helpful. Benign paroxysmal positional vertigo can be treated with a canalith repositioning procedure (e.g., Epley maneuver). Treatment of Meniere disease includes salt restriction and diuretics. Symptoms of vestibular neuritis are relieved with vestibular suppressant medications and vestibular rehabilitation.

Full reference: Muncie, H. et al. (2017) Dizziness: Approach to Evaluation and Management. American Family Physician. Vol. 95 (no. 3) pp. 154-162.


Diagnosing, Treating Benign Paroxysmal Positional Vertigo

Updated guidelines on the diagnosis and treatment of benign paroxysmal positional vertigo (BPPV) suggest a series of in-office maneuvers, rather than expensive imaging tests or medications, offer a faster route to diagnosis and cure | ED Management

  • Typically, patients with BPPV present with symptoms of intense dizziness that may be accompanied by nausea, vomiting, or an intense feeling of disorientation or instability.
  • A very specific diagnostic step called the Dix-Hallpike maneuver can enable physicians to quickly spot the signs of BPPV.
  • When the diagnosis is positive for BPPV, canalith repositioning maneuvers typically can resolve the symptoms.
  • When BPPV is suspected, guideline authors urged providers to stay away from vestibular suppressive medications, which produce a host of side effects and can contribute to a delay in diagnosis.

Full reference: Bhattacharyya, N. et al. (2017) Diagnosing, Treating Benign Paroxysmal Positional Vertigo. ED Management. Online issue: 1st August 2017

Anxiety and panic agarophobia scores in patients with BPPV

Kahraman, S.S. et al. (2017) Acta Oto-Laryngologica. 137(5) pp. 485-489

Objective: Recent studies have shown that people with dizziness report some psychological problems such as panic and agoraphobia and anxiety. The aim of this study was to evaluate anxiety and panic agorophobia levels in patients with benign paroxysmal positional vertigo (BPPV) on initial presentation and at the follow-up visit and compare the scores with the control group.

Conclusion: Patients with BPPV experienced short but intense anxiety and/or panic disorder, especially at the initial visit, but most patients recovered without medication with successful treatment.

Read the abstract here

Effects of Semont maneuver on benign paroxysmal positional vertigo

Zhang, X. et al. (2017) Acta Oto-Laryngologica. 137(1) pp. 63-70

Image source: Dr David Furness – Wellcome Images // CC BY-NC-ND 4.0

Image shows scanning electron micrograph of Stereocilia in the vestibular organ

Background: Benign paroxysmal positional vertigo (BPPV) is the most common type of peripheral vertigo. This study aimed to evaluate the effects of the Semont maneuver (SM) for BPPV treatment, compared with other methods.

Methods: Studies were selected in relevant databases under pre-defined criteria up to June 2015. The Cochrane evaluation system was used to assess the quality of the studies. Effect size was indicated as a risk-ratio (RR) with corresponding 95% confidential interval (CI). Statistical analysis was conducted under a randomized- or fixed-effects model. Sub-group analysis was performed.

Conclusion: SM is as effective as EM and BDE for BPPV treatment.

Read the full abstract here