Sorting out vertigo
A shift in diagnostic approach for vertigo involves asking about the timing and triggers for episodes rather than a description of symptoms.
For patients and physicians, the underlying cause of vertigo or dizziness can be frustrating and sometimes time-consuming to sort out. But a diagnostic workup focused on the timing and triggers of symptoms, along with related interventions such as physical therapy, can go a long way toward providing relief, according to experts.
The lifetime prevalence of significant dizziness ranges between 17% and 30%, according to a systematic review published in 2015 in Otology & Neurotology. Vertigo prevalence also varied widely, between 3% and 10%.
Nearly one-fourth of patients seek medical care for dizziness through the ED, according to an analysis of claims data involving 805,454 patients, published in January 2022 by Otolaryngology–Head and Neck Surgery. Most patients are treated at outpatient clinics, three-quarters of them by primary care physicians, and the remainder by otolaryngologists, cardiologists, and neurologists. The patients' median age is 52 years, nearly two-thirds are female, and 29% are Black, Hispanic, or Asian adults.
Vertigo and dizziness can be spontaneous or triggered. Vertigo is typified by a sensation of self-motion when no self-motion is occurring, or by distorted self-motion during an otherwise normal head movement, according to an April 2021 review article for the American Academy of Neurology that looked at the evaluation of vertigo and dizziness. In cases of dizziness, the individual feels a disturbed or altered spatial orientation without a feeling of false motion.
However, research shows that the specific descriptive word that a patient uses has little diagnostic value, said Jonathan A. Edlow, MD, a professor of medicine and emergency medicine at Harvard Medical School and an emergency physician at Beth Israel Deaconess Medical Center in Boston.
“Vertigo is a symptom just like belly pain or chest pain or headache, and you have to find the cause of that symptom,” he said. A shift in diagnostic approach, which has emerged based on research over the last two decades, involves asking patients with a suspected vestibular disorder about the timing and triggers for their dizziness or vertigo, rather than relying more on a description of their symptoms, said Dr. Edlow, one of the first authors on the most recent guideline on acute dizziness and vertigo in the ED, dubbed GRACE-3, which was published in May 2023 in Academic Emergency Medicine.
Patients currently experience delays in diagnosis and other frustrations. In one study, 42% of 521 patients with dizziness surveyed through the Vestibular Disorder Association reported seeking medical care within the first week of symptoms. Yet, nearly half (44%) weren't diagnosed for six months or longer, according to the findings, published in 2016 in Otology & Neurotology. Slightly more than half of the patients reported falling due to their dizziness.
The symptoms, along with being miserable, also can be isolating, said Pamela Dunlap, DPT, PhD, a researcher and an assistant professor of physical therapy at the University of Pittsburgh School of Health and Rehabilitation Sciences.
“It can really impact people's lives,” she said. “They might stop working. Or with BPPV [benign paroxysmal positional vertigo], I've treated individuals who sleep sitting up because they don't want to experience dizziness when they lie down.”
Sorting out the diagnosis
When a patient presents with dizziness or vertigo, “probably about half of the time it has nothing to do with the brain or the inner ear,” said Dr. Edlow, citing his own experience, as well as prior research. The first step, he stressed, is to make sure the patient isn't having a stroke. In addition to the dizziness, is the patient dysarthric? Do they have a facial droop? Basically, is the dizziness isolated or are there other neurological symptoms that make a stroke more likely?
Once that's done, physicians can review the vital signs and conduct a history to figure out if the symptoms are rooted in one of many general medical causes. The patient may have recently started a new blood pressure medication, may be in the early stages of sepsis, or may have experienced heavy vaginal bleeding that proves to be an ectopic pregnancy, he said, ticking off several of many diagnostic possibilities.
After that, physicians can direct their questions to the timing and triggers of the dizziness or vertigo that could identify a vestibular disorder, Dr. Edlow said. The approach is similar to the workup for other symptoms, such as chest pain, in which the focus is less on the patient's description and more on timing, triggers, and other context, he said. If the symptoms come and go, physicians can ask how long they last when they do emerge. Also, can the patient identify a trigger tied to their onset?
If dizziness occurs when a patient abruptly stands from a prone position, it might be postural hypotension, Dr. Edlow said. In other instances, the patient might report that they develop the symptoms when they roll over in bed or tilt their head back as they reach for something on a high shelf, which points to BPPV as a possibility, he said.
BPPV, one of the most common causes of vertigo, occurs when calcium carbonate particles, called otoconia, fall into the inner ear canal and move around. These recurring vertigo episodes are typically brief, no longer than 30 seconds, said Terry D. Fife, MD, director of vestibular neurology and balance disorders at the Barrow Neurological Institute in Phoenix.
In some cases, patients may have already recognized that vertigo hits when they move their head in a certain way. “It's usually described as spinning,” Dr. Fife said. With other patients, “they haven't put two and two together,” connecting the head movement to the onset of spinning. But physicians can assist them with identifying a trigger, he said.
Unlike BPPV, which requires a trigger to spur the vertigo or dizziness, some other types of episodic vestibular syndromes occur spontaneously, said Dr. Fife, who authored the April 2021 review article for the American Academy of Neurology. One example is Ménière's disease, in which the symptoms typically last one to six hours, including intense vertigo, nausea, and vomiting, he said.
With Ménière's disease, one ear is often more affected than the other, Dr. Fife said. Patients may report a sense of fullness in one ear or an atypical ringing or reduced hearing around the time of the attack, he said. “That would be clues that the patient has Ménière's,” he said. If the attack lasts more than 24 hours, he added, then the cause is not Ménière's.
Given that part of the diagnosis for classic Ménière's disease involves two or more spontaneous attacks of vertigo, each lasting 20 minutes to 12 hours, identifying the condition can require many months, since the cause of the first vertigo episode may be unclear, said Gregory Basura, MD, PhD, an associate professor of otolaryngology-head and neck surgery at the University of Michigan in Ann Arbor and a lead author on a clinical practice guideline for Ménière's disease.
Vestibular migraine can be “a great mimicker” of Ménière's, as it can develop without a headache, Dr. Basura said. Patients may also report ear-related symptoms, such as tinnitus or fullness, but they're typically not as severe as with Ménière's, and the migraine-related bouts of vertigo are typically shorter or longer: “They can last the whole day.” Dr. Basura suggested referring the patient to a subspecialist, such as an otolaryngologist, to distinguish between the two.
Since numerous conditions can cause dizziness or vertigo, physicians can suggest that frustrated patients keep a diary to more quickly home in on a diagnosis, Dr. Basura said. Ask patients to describe their symptoms with as much detail as possible, he said, avoiding the word “dizziness.” Do they feel lightheaded or like they are rocking on a boat, or is it more of a spinning sensation?
Also, track the time and date when the sensations occurred, along with other details. What were they doing when the dizziness or vertigo flared? What food had they eaten recently?
But Dr. Basura and other physicians emphasized that patients should be sent directly to the ED if their symptoms are acute and can't be explained, for instance, a patient who is very nauseated with vertigo “and they are in the throes of it,” Dr. Fife said. The cause is much more likely to be a viral inner ear infection, such as vestibular neuritis, Dr. Fife said, “but a small percentage of those [cases] can be an isolated stroke or a TIA [transient ischemic attack].”
Providing relief
For patients with BPPV, the canalith repositioning maneuver and several related maneuvers are by far the most effective treatment, Dr. Fife said. In a single session, the procedure will provide relief in about 90% of cases. “The patient can walk out without symptoms,” he noted. Successful treatment doesn't prevent a recurrence, as other particles can dislodge, triggering symptoms.
Primary care physicians who may not have been taught the repositioning maneuvers in medical school can instead refer patients to a physical therapist, Dr. Fife said. For physicians interested in more training in diagnosis and related procedures, including videos, Dr. Edlow cited the Neuro-Ophthalmology Virtual Education Library.
A study that Dr. Dunlap and colleagues conducted found that physical therapy referrals were rare for dizziness-related symptoms. Primary care physicians referred fewer than 1% of patients seeking care for dizziness or a vestibular disorder to a physical therapist, according to the findings, published in 2019 in Otology & Neurotology. The physical therapy referral rate among neurologists, 3.3% of patient visits, was a bit higher.
Physical therapists are trained in the Dix-Hallpike maneuver and the supine roll test, both used to diagnose BPPV, along with canalith repositioning maneuvers, Dr. Dunlap said. To treat BPPV, she performs at least two repositioning maneuvers in a single session. She typically asks patients to return so she can assess if they still have BPPV, using one of the diagnostic tests. If they don't, she educates them that the condition can recur and to return if it does.
But Dr. Dunlap doesn't teach patients to perform the maneuvers on their own, citing safety concerns. “If someone is by themselves and they're trying to do these maneuvers alone, I have concerns about severe symptoms and risk for falling out of bed because they are dizzy,” she said.
Physical therapy, when provided within three months after a patient seeks medical care for dizziness, can reduce the risk of the patient's falling by 86% over the next nine months, according to findings published online Sept. 14, 2023, in JAMA Otolaryngology–Head & Neck Surgery. The clinical value of two commonly prescribed classes of medications, antihistamines and benzodiazepines, is less clear-cut. And the cause of dizziness is important, Dr. Edlow said. For example, for BPPV, the treatment is a simple bedside physical maneuver, not medication.
A recent systematic review and meta-analysis published in September 2022 in JAMA Neurology didn't find benefit with benzodiazepines for treating acute vertigo of any cause. Based on the results, “I just concluded at least for my own practice that we really shouldn't be using benzodiazepines for this,” said Ben Hunter, MD, the study's lead author and a professor of emergency medicine at Indiana University School of Medicine in Indianapolis.
A single dose of antihistamines showed some benefit in easing acute vertigo within the first two hours, compared with a single dose of benzodiazepines. Antihistamines may also help if taken for up to one to two weeks, Dr. Hunter said, adding “I would call it very weak and inconsistent evidence.” If there's a benefit, he said, “it's almost certainly small.”
Medication can provide patients with relief in situations where a specific diagnosis has been made, such as vestibular migraine, Dr. Fife said. In those cases, various migraine preventive medications—beta-blockers, calcium-channel blockers, and tricyclic antidepressants, among others—may help prevent and reduce dizziness, he said.
In cases of suspected Ménière's disease, primary care physicians should ideally refer the patient to a subspecialist to confirm the diagnosis, Dr. Basura said. But until the patient can be seen, physicians can take several initial steps, including shifting patients to a low-sodium diet, a transition that may need to be made in stages over weeks if current consumption is high, he said.
If the low-sodium diet doesn't stop the vertigo attacks, the next step would be to prescribe a diuretic, Dr. Basura said. It's also important that physicians get the patient's hearing tested as soon as feasible, he said.
Physicians can prescribe meclizine in an effort to abort vertigo attacks, since patients often experience tinnitus and other ear-related symptoms first and can take the drug before the vertigo kicks in, Dr. Basura said. But he cautioned that patients should only use the medication as directed and should not take it regularly on an ongoing basis, despite their fears of another attack.
Given that Ménière's disease damages the inner ear over time, ongoing use of central-acting vestibular suppressants, including meclizine (Antivert), diazepam (Valium), and lorazepam (Ativan), among others, can inhibit the brain's ability to learn and adjust to the greater damage in one ear versus the other, Dr. Basura said. As a result, patients can feel “like they are chronically imbalanced,” as if they had consumed too much alcohol, he said.
When referring a patient to a subspecialist for diagnostic guidance, physicians can facilitate care by being as specific as possible about the patient's symptoms, Dr. Edlow said. Rather than describing the patient as dizzy, they can specify that the symptoms have been intermittent over six months, lasting three hours at a stretch, and that the patient's office exam is normal, he said.
But primary care physicians also can diagnose and provide some relief in their own offices more frequently than they realize, particularly if they keep their diagnostic workup tight on timing and triggers and learn repositioning maneuvers, Dr. Edlow said.
“There tends to be a resistance to learning new things about dizziness,” he said. “And I think it's because the old paradigm that we've all been taught just doesn't work a lot of the time. The reality is that learning a few simple things can really help you take better care of these patients, and actually make you enjoy taking care of dizzy patients.”
