J Korean Med Assoc.  2010 Oct;53(10):898-910. 10.5124/jkma.2010.53.10.898.

Evaluation and treatment of the patient with acute dizziness in primary care

• Lim HW
• Chae SW

• KMID: 2188415
• DOI: http://doi.org/10.5124/jkma.2010.53.10.898

Abstract

Dizziness is a very common symptom encountered by primary care physicians. Dizziness can be divided into five subgroups according to symptoms. These subgroups can be determined by a patient's history and allow the physician to deduce the etiology. A careful and systematic approach to dizzy patients is the key to a correct diagnosis and finding the optimal treatment. Physicians should obtain a detailed history from the patient in an open-ended fashion. Brief and comprehensive bedside neuro-otologic examinations, such as cranial nerve examinations, the Dix-Hallpike test, and the head thrust test cannot be omitted for an accurate diagnosis. Knowledge about the numerous disease entities that may contribute to dizziness can be essential for differential diagnosis. In addition, this article provides information about frequently prescribed drugs, including vestibular suppressants and antiemetics.

Keyword

Acute dizziness; History-taking; Examination; Drug therapy

MeSH Terms

Antiemetics
Cranial Nerves
Diagnosis, Differential
Dizziness
Head
Humans
Physicians, Primary Care
Primary Health Care
Antiemetics

Figure

• 

  Figure 1 Physiology of the head thrust test. Head movement towards a canal will cause activation of that canal. Reflex movement of the eyes in the opposite direction- that is, away from the canal (A). Head movement towards a defunct canal will result in the failure of activation of the vestibulo-ocular reflex and thus the visual target will be lost from fixation during sudden head movements (B).

• 

  Figure 2 Sit the patient upright. Turn the patient's head to the affected side at a 45 degree angle (A). The patient is brought into the supine position with the head extended below the level of the bed (Dix-Hallpike position) (B). Maintain up to 30 seconds after nystagmus disappears (C). Turn the patient's head 90 degrees to the other side (D). The patient's head is further rotated to the opposite side by rolling until the patient is face down (E). The patient is brought back to the upright position (F).

Reference

1. Nazareth I, Landau S, Yardley L, Luxon L. Patterns of presentations of dizziness in primary care-a cross-sectional cluster analysis study. J Psychosom Res. 2006. 60:395–401.

2. Karatas M. Central vertigo and dizziness: epidemiology, differential diagnosis, and common causes. Neurologist. 2008. 14:355–364.

3. Colledge NR, Wilson JA, Macintyre CC, MacLennan WJ. The prevalence and characteristics of dizziness in an elderly community. Age Ageing. 1994. 23:117–120.

4. Kroenke K, Lucas CA, Rosenberg ML, Scherokman B, Herbers JE Jr, Wehrle PA, Boggi JO. Causes of persistent dizziness. A prospective study of 100 patients in ambulatory care. Ann Intern Med. 1992. 117:898–904.

5. Dieterich MMD. Dizziness. Neurologist. 2004. 10:154–164.

6. Chawla N, Olshaker JS. Diagnosis and management of dizziness and vertigo. Med Clin North Am. 2006. 90:291–304.

7. Egger S, Zee D. Cummings C, Flint P, Harker L, editors. Central vestubular disorders. Otolaryngology, Head and Neck Surgery. 2005. 4 ed. St. Louis: Mosby;3254–3288.

8. Farrehi PM, Santinga JT, Eagle KA. Syncope: diagnosis of cardiac and noncardiac causes. Geriatrics. 1995. 50:24–30.

9. Eckhardt A, Tettenborn B, Krauthauser H, Thomalske C, Hartmann O, Hoffmann SO, Hopf HC. [Vertigo and anxiety disordersresults of interdisciplinary evaluation]. Laryngorhinootologie. 1996. 75:517–522.

10. Chan Y. Differential diagnosis of dizziness. Curr Opin Otolaryngol Head Neck Surg. 2009. 17:200–203.

11. Hullar T, Zee D, Minor L. Flint P, Haughey B, Lund V, editors. Evaluation of the Patient with Dizziness. Cummings Otolaryngology Head&Neck Surgery. 2010. 5 ed. Philadelphia: Mosby;2303–2327.

12. Hüfner K, Barresi D, Glaser M, Linn J, Adrion C, Mansmann U, Brandt T, Strupp M. Vestibular paroxysmia: Diagnostic features and medical treatment. Neurology. 2008. 71:1006–1014.

13. Kroenke K, Mangelsdorff AD. Common symptoms in ambulatory care: incidence, evaluation, therapy, and outcome. Am J Med. 1989. 86:262–266.

14. Brandt T, Strupp M. General vestibular testing. Clin Neurophysiol. 2005. 116:406–426.

15. Baloh RW. Baloh RW, editor. Approach to the patient with dizziness. Dizziness, Hearing Loss, and Tinnitus. 1998. Philadelphia: F.A. Davis Company.

16. Hain T, Micco A. Goetz C, Pappert E, editors. Neuroanatomical localization and syndromes, cranial nerve III: VESTIBULOCOCHLEAR SYSTEM. Textbook of Clinical Neurology. 1999. 1 ed. Philadelphia: WB saunders company;184–199.

17. Baloh RW. Vertigo. Lancet. 1998. 352:1841–1846.

18. Cha CI. Korean society of otorhinolaryngology. Differential diagnosis of dizziness. Otorhinolaryngology Head and Neck Surgery. 2009. 2nd ed. Ilchokak;876–897.

19. Solomon D. Distinguishing and treating causes of central vertigo. Otolaryngol Clin North Am. 2000. 33:579–601.

20. Seemungal BM. Neuro-otological emergencies. Curr Opin Neurol. 2007. 20:32–39.

21. Chae SW. Acute spontaneous vertigo. J Korean Bal Soc. 2008. 7:231–238.

22. Harvey SA, Wood DJ, Feroah TR. Relationship of the head impulse test and head-shake nystagmus in reference to caloric testing. Am J Otol. 1997. 18:207–213.

23. Chung W, Chung K. Diagnostic Approach to a Patient with Dizziness. J Korean Bal Soc. 2007. 6:73–79.

24. Epley JM. New dimensions of benign paroxysmal positional vertigo. Otolaryngol Head Neck Surg. 1980. 88:599–605.

25. Prokopakis EP, Chimona T, Tsagournisakis M, Christodoulou P, Hirsch BE, Lachanas VA, Helidonis ES, Plaitakis A, Velegrakis GA. Benign paroxysmal positional vertigo: 10-year experience in treating 592 patients with canalith repositioning procedure. Laryngoscope. 2005. 115:1667–1671.

26. Bhattacharyya N, Baugh R, Orvidas L, Barrs D, Bronston L, Cass S. Clinical practice guideline: Benign paroxysmal positional vertigo. Otolaryngology-Head and Neck Surgery. 2008. 139:S47–S81.

27. Bergenius J, Perols O. Vestibular neuritis: a follow-up study. Acta Otolaryngol. 1999. 119:895–899.

28. Minor LB, Schessel DA, Carey JP. Meniere's disease. Curr Opin Neurol. 2004. 17:9–16.

29. Crane BT, Schessel DA, Nedzelski J, Minor LB. Flint P, Haughey B, Lund V, editors. Peripheral vesibular disorders. Cummings Otolaryngology Head&Neck Surgery. 2010. Philadelphia: Mosby;2328–2345.

30. Lempert T, Neuhauser H. Migrainous vertigo. Neurol Clin. 2005. 23:715–730. vi.

31. Neuhauser HK, Lempert T. Diagnostic criteria for migrainous vertigo. Acta Otolaryngol. 2005. 125:1247–1248.

32. Furman JM, Marcus DA, Balaban CD. Migrainous vertigo: development of a pathogenetic model and structured diagnostic interview. Curr Opin Neurol. 2003. 16:5–13.

33. Lee H, Cho YW. A case of isolated nodulus infarction presenting as a vestibular neuritis. J Neurol Sci. 2004. 221:117–119.

34. Lee H, Sohn SI, Jung DK, Cho YW, Lim JG, Yi SD, Lee SR, Sohn CH, Baloh RW. Sudden deafness and anterior inferior cerebellar artery infarction. Stroke. 2002. 33:2807–2812.

35. Baloh RW. Clinical practice. Vestibular neuritis. N Engl J Med. 2003. 348:1027–1032.

36. Tighilet B, Leonard J, Lacour M. Betahistine dihydrochloride treatment facilitates vestibular compensation in the cat. J Vestib Res. 1995. 5:53–66.

37. Shinkawa H, Kimura RS. Effect of diuretics on endolymphatic hydrops. Acta Otolaryngol. 1986. 101:43–52.