Episodic Spontaneous Dizziness

PURPOSE OF REVIEW Conditions causing recurrent spontaneous episodes of dizziness or vertigo span several medical specialties, making it challenging for clinicians to gain confidence in evaluating and managing the spectrum of episodic vestibular disorders. Patients are often asymptomatic and have normal examinations at the time of evaluation. Thus, diagnosis depends heavily on eliciting key features from the history. Overreliance on symptom quality descriptions commonly leads to misdiagnosis. The goal of this article is to provide the reader with a straightforward approach to the diagnosis and management of conditions that cause episodic spontaneous dizziness.

RECENT FINDINGS Consensus diagnostic criteria have been established for vestibular migraine, Ménière disease, vestibular paroxysmia, and hemodynamic orthostatic dizziness/vertigo. Vertigo has been recognized as a common symptom in vertebrobasilar ischemia, cardiogenic dizziness, and orthostatic hypotension. Treatment recommendations for vestibular migraine still lack high-quality evidence, but controlled trials are occurring.

SUMMARY The evaluation should start with a detailed description of the episodes from the patient and any observers. Rather than focusing first on whether the symptom quality is most consistent with vertigo, dizziness, lightheadedness, or unsteadiness, the clinician should clarify the timing (episode frequency and duration), possible triggers or circumstances (eg, position changes, upright posture), and accompanying symptoms. History should identify any auditory symptoms, migraine features, posterior circulation ischemic symptoms, vascular risk factors, clues for anxiety, and potentially relevant medications. Carefully selected testing can help secure the diagnosis, but excessive and indiscriminate testing can lead to more confusion. Treatments for these conditions are vastly different, so an accurate diagnosis is critical.

Address correspondence to Dr Scott Eggers, Department of Neurology, Mayo Clinic, 200 First St SW, Rochester, MN 55905, [email protected].

RELATIONSHIP DISCLOSURE: Dr Eggers has received research/grant support from the National Institutes of Health/National Institute on Deafness and Other Communication Disorders (U01 DC13256), publishing royalties from UpToDate, Inc, and technology intellectual property royalty payments from the Mayo Clinic.

UNLABELED USE OF PRODUCTS/INVESTIGATIONAL USE DISCLOSURE: Dr Eggers discusses the unlabeled/investigational use of amitriptyline, atenolol, betahistine, cinnarizine, cyproheptadine, diazepam, diltiazem, dimenhydrinate, flunarizine, gabapentin, lamotrigine, lomerizine, lorazepam, metoclopramide, metoprolol, nortriptyline, pizotifen, venlafaxine, and verapamil, none of which are approved by the US Food and Drug Administration (FDA) for the treatment of vestibular migraine; carbamazepine, lacosamide, and oxcarbazepine, none of which are FDA approved for the treatment of vestibular paroxysmia; and rizatriptan, which is not FDA approved for the treatment of motion sickness.