Dizziness is a common presenting symptom among patients in many settings, but half of patients with dizziness present to primary care clinics.1 It is a nonspecific term used to describe a subjective sensation that patients may find difficult to fully explain.2 Dizziness involves a sense of compromised spatial orientation.3 Studies have confirmed that dizziness occurs in about 15% to 20% of adults nationwide every year.4 The prevalence of dizziness increases with age and is higher in women than men.4 This article will review numerous causes of dizziness, with a focus on vestibular dysfunction, which is the most common cause of dizziness. Diagnostic testing, treatment options, and patient education are also discussed.
Classification of dizziness
Various broad concepts have been used in the literature to describe and classify dizziness. These categories include vertigo, disequilibrium, presyncope or syncope, lightheadedness, and nonspecific dizziness.1,2,5,6 Symptom descriptors may indicate the potential cause. Although the classifications of dizziness are not standardized, NPs may still find these five groupings helpful when delineating differential diagnoses.
Vertigo. Vertigo is the most frequent classification associated with dizziness. It is generally defined as the sensation of motion when still or a perception of distorted motion with normal head movement.3 A sensation of spinning is also linked with vertigo.7 External vertigo is a vestibular-visual symptom characterized by this false sense that the external environment is spinning.3 Vertigo is the result of dysfunction of the vestibular system, which involves many intricate components of the inner ear and complex neurologic connections in the brain.8 The vestibular system also contributes to various aspects of movement and gait, balance, stance, vision, spatial orientation, and memory.3 The slightest disturbance of the vestibular system can result in vertigo.1 Although the terms dizziness and vertigo are sometimes used interchangeably, vertigo describes a specific sensation and is considered a classification of the broad symptom of dizziness.
Disequilibrium. Disequilibrium is a frequently used term in the literature to describe a sense of insecurity, imbalance, or unsteadiness when walking.2 If the patient reports a feeling of falling, the NP should consider this a depiction of disequilibrium.7 The term unsteadiness can be substituted for disequilibrium, and further might be a more-effective translation for patients to describe the instability experienced while sitting, standing, or walking.3,9
Presyncope and syncope. Presyncope describes a feeling of threatening or imminent fainting.5,7 In contrast, syncope involves the actual temporary loss of consciousness.5 The term fainting may be substituted for presyncope or syncope.7 This classification of dizziness is important for the NP to delineate and distinguish from vertigo and disequilibrium, which describe motion or movement disturbance, because syncope it is often a result of cerebral hypoperfusion or a cardiac abnormality.5
Lightheadedness. This is a vague term and can be clarified as “wooziness” or a sense that one might be close to fainting.1,2 Lightheadedness is often correlated with the presyncope category because of similarity. To further blur this distinction, lightheadedness can be linked with vertigo or disequilibrium conditions as well.2 Because of this overlap in class distinction, consensus is emerging that de-emphasizes the terms disequilibrium, presyncope, and lightheadedness.9
Nonspecific dizziness. Nonspecific dizziness is often difficult for the patient to describe and lacks diagnostic physical exam findings.8 A variety of etiologies are associated with nonspecific dizziness, such as depression, anxiety, hyperventilation, and adverse reactions of medications.8
The differential list for dizziness is lengthy, which can make it a daunting presenting symptom for both the novice and experienced NP. (See Dizziness classifications with respective differential diagnoses.) Although dizziness is a symptom with a diverse set of etiologies, some are more frequently encountered. A prospective study in ambulatory care settings found that peripheral vestibular dysfunction, which is associated with vertigo, was the most frequent cause of persistent dizziness, representing about 40% of cases.8,15 Roughly 25% of patients with dizziness fell into other classifications of presyncope, disequilibrium, or multicausal due to causes from more than one category; approximately 15% had a psychiatric cause, about 10% had a central cause, and the remaining 10% had an unclear etiology.8,15 In older adults, stroke is the most common central cause of vertigo.8
Alcohol and some medications also have been identified as contributors to dizziness.1,5,16 Medications were implicated in 23% of dizziness in older adults in a primary care setting.1,5,17 Orthostatic hypotension can also trigger dizziness and certain medications can exacerbate these symptoms. Medications with the potential to cause various types of dizziness are antiepileptics, antihypertensives, antibiotics (such as aminoglycosides), antidiabetic agents, sedatives, psychotropic drugs, corticosteroids, aspirin, and diuretics such as furosemide, as well as others.1,5,10,16 Knowing key clinical presentations of each etiology allows NPs to make the appropriate dizziness diagnosis.
As with most clinical diagnoses, many critical elements can be elicited from the patient history; the diagnosis for the patient's dizziness is revealed about 75% of the time from the history alone.11 NPs must be able to recognize red flags associated with serious conditions and differentiate them from benign conditions. It can be helpful to begin the patient interview with a broad opening question, such as, “Can you describe your dizziness?”5 Although patients may struggle to describe the quality of their dizziness, they can often explain triggers and the timing of symptoms.1,18
TiTrATE is a novel diagnostic approach to determining the probable etiology of dizziness and includes timing of the symptom, triggers that provoke the symptom and a targeted examination.1 Timing can refer to the length of dizziness symptoms or episodes, which can last seconds, hours, days, or weeks.1 Movement can be a common trigger, so NPs should ask their patients if the dizziness is elicited with movement of the head or changing positions.1 The Valsalva maneuver, orthostasis, and visual or auditory stimuli are examples of other potential triggers.3 Patients with dizziness may also report head trauma, which is usually categorized as peripheral vertigo.2 Head trauma could also cause central symptoms or nonspecific dizziness.8,10
Patients with dizziness can have other related symptoms, such as nausea, vomiting, diaphoresis, tinnitus, changes in hearing or hearing loss, ear pain or pressure, or blurry vision or other visual change.2,5 Headache, photophobia, phonophobia, and visual aura may be correlated with a vestibular migraine.12 NPs should suspect a central cause of dizziness if a patient has positive neurologic findings, vertigo, and nausea that is not related to position.2 Patients with dizziness also may report unsteadiness, imbalance, or other changes of gait.2,5,13 In contrast, patients with central vertigo are often severely unstable and have difficulty walking without falling.8 Brainstem involvement with vertigo, such as a central vestibular lesion, should be suspected if a patient reports the following neurologic symptoms: staggering or ataxic gait, vomiting, headache, double vision, visual loss, slurred speech, numbness of the face or body, weakness, clumsiness, or incoordination.8
Vertigo: Peripheral and central vestibular dysfunction
Vertigo is described as an illusion of motion that can manifest with a patient's positional changes or while a patient is still.13 Vertigo encompasses peripheral and central causes, with about 90% of vertigo cases having a peripheral etiology.7 Common peripheral causes include benign paroxysmal positional vertigo (BPPV), vestibular neuritis, and Ménière disease.1 Vestibular migraine is a common central cause of vertigo.1
BPPV. BPPV is the most common cause of vertigo and is a disorder of the inner ear.7,11,19 It is caused by canalithiasis of the semicircular ear canal in which debris caused by calcium creates loose crystals in the canal.1,20 Shifts in gravity and movement of the crystals precipitate a sensation of movement in these patients.20 BPPV may be of the posterior or lateral semicircular canals, but posterior canal BPPV occurs in 85% to 95% of cases.19 BPPV occurs more commonly in women, and in men and women ages 50 to 70.1,19 A definitive cause is not determined in more than half of cases, although head trauma or prior viral inner ear infection is sometimes identified.2 When younger patients are diagnosed with BPPV, it is often related to head trauma.21
The dizziness related to BPPV is typically episodic.1,11 BPPV lasts less than 1 minute and is triggered by a change in position of the head position.11,21 It may be relieved by stillness and can involve nausea and vomiting.7,11 A patient may experience a singular episode or symptoms may occur and recur in clusters.7,19 BPPV is not associated with hearing loss or tinnitus.11
Vestibular neuritis. Vestibular neuritis is the second most common cause of vertigo and is another diagnosis related to the peripheral vestibular system.1,11 Its pathogenesis involves inflammation of the vestibular component of the eighth cranial nerve and it is most often caused by a viral infection.11,14 It presents in men and women equally.1 Symptoms are sudden, continuous, and can last for days to weeks.1,10 The vertigo may be associated with nausea, or gait instability, and hearing is not affected.1,11
Ménière disease. Ménière disease is a potentially severe and disabling type of vertigo that is caused by increased fluid in the inner ear.11,22 It has a familial tendency and is more common in patients ages 20 to 60.11,22 It is a peripheral vestibular diagnosis presenting with episodic vertigo that can last for hours, tinnitus, and unilateral hearing loss.1,10,11 When audiometric testing is performed on patients with this disease, low- to medium-frequency sensorineural hearing loss is documented in the affected ear.1 Individuals may experience extended periods of nausea and vomiting and loss of balance.11 It is not triggered by movement, but may have other triggers, such as allergies, diet, stress, and illness.11
Vestibular migraine. Vestibular migraine is a common central cause of vertigo that may be diagnosed when a patient with a migraine or history of migraines also experiences vertigo.1,23 It is seen more often in patients ages 30 to 50 and more commonly in women.23 Family history is also a recognized risk factor, making patient history a critical element of diagnosis.1 Vestibular migraine is a common cause of vertigo in children, but it may be more difficult for them to explain their vertigo symptoms.1,24 A headache may concurrently accompany the dizziness.12 There are very specific diagnostic criteria for the diagnosis of vestibular migraine, including:23,25
- current or past history of migraine (with or without aura)
- at least five episodes meeting both of the following two criteria:
- – vestibular symptoms of moderate or severe intensity (interfering with or preventing daily activities) are present and last between 5 minutes and 72 hours
- – at least half of episodes are associated with at least one of the following migraine features:
- headache with at least two migraine characteristics
- photophobia and phonophobia
- visual aura
- no other diagnosis accounts for the patient's symptoms.
Psychogenic. Psychogenic dizziness has been linked with psychiatric disorders such as depression, anxiety, panic, agoraphobia, and somatization.1,2,8,10 Symptoms are often vague with a long duration that may last for years.7,10 Psychogenic dizziness may be considered as being in either the nonspecific dizziness or the presyncope/syncope category.2,7 Hyperventilation may be related to this type of dizziness.5,10,11 It is important to consider that dizziness itself is frustrating to patients and impacts quality of life, and this could precipitate some anxiety and apprehension even for patients with nonpsychogenic causes of dizziness.2 Thus, if anxiety is reported with dizziness, it is appropriate to complete a systematic evaluation to determine if the cause is psychogenic or the patient is experiencing distress because of the ongoing symptoms of dizziness.
The physical exam for a patient with dizziness is detailed and should include a thorough cardiac and neurologic assessment along with a complete examination of the head, eyes, ears (including hearing), nose, and throat.1 NPs should also be familiar with the Dix-Hallpike maneuver, which is useful in diagnosing BPPV.1 (See Dizziness resources.) Although most patients presenting with dizziness will have benign causes, it is important for the NP to identify red flags for potentially life-threatening etiologies, such as a stroke.
A HINTS exam, which tests head impulse, nys-tagmus, and test of skew, has been shown effective at differentiating an acute stroke (central cause) from a peripheral cause of dizziness, such as vestibular neuritis.26 Head impulse is tested by the NP gently rotating the seated patient's head to the right and left with more rapid movement to center. During this test, the patient's eyes remain focused on a fixed object. If the patient has saccadic eye movements, it indicates a peripheral cause of dizziness. The absence of eye movement indicates a higher likelihood of central etiology.1
It is important to test for nystagmus with all complaints of dizziness and it can occur with peripheral or central causes.1 To test for nystagmus, the patient's eyes should follow the NP's finger as the NP moves them through the cardinal directions of gaze. Horizontal nystagmus is associated with a peripheral cause and spontaneous nonhorizontal nystagmus can indicate a central lesion.1 The final component in the HINTS assessment is the test of skew. Test of skew is performed by the patient gazing straight ahead as the examiner covers and uncovers each eye. Brainstem pathology is indicated if the patient's covered eye deviates vertically.1
Observe gait, heel-to-shin testing, and tandem walking to assess proprioception.27 Gait disturbance can indicate cerebellar dysfunction or peripheral neuropathy.
BP should be measured in the supine and standing positions to rule out orthostatic hypotension.1 Orthostatic hypotension is diagnosed when BP and heart rate is measured after the patient has been supine for 5 minutes. The patient should then be asked to stand and BP and heart rate again measured at the 1- and 3-minute intervals.28 A decrease of more than 20 mm Hg systolic or 10 mm Hg diastolic, or an increase in heart rate by more than 30 beats/minute is indicative of orthostatic hypotension.1,28
Most cases of dizziness and vertigo can be differentiated with a thorough history and physical exam.29 Routine use of brain imaging, vestibular testing, audiometry and lab testing without appropriate indications have been discouraged because of high expense and low yield.11 One analysis concluded that less than 1% of the patients studied had a lab result that explained their dizziness.1 However, if there is a suspected contributing medical condition, such as diabetes mellitus or hypertension, tests would be considered, such as blood glucose and electrolyte measurements.1 Other possible lab tests include thyroid function, complete blood cell count, creatinine, vitamin B 12, and serologic testing for syphilis with rapid plasma reagin.2,5 Audiometry should be performed with hearing loss.10 Diagnostic testing is needed for some serious causes of dizziness, such as cerebrovascular disease and cardiac arrhythmias.11 A complete workup with lab tests and diagnostic testing may be required for central vertigo to determine the actual cause.5
Routine imaging is not indicated for dizziness and vertigo; however, further testing with neuroimaging studies is warranted if there are pertinent risk factors, abnormal neurologic findings, or progressive unilateral hearing loss.1,16 These studies include computed tomography or MRI and can evaluate for cerebrovascular disease, acoustic neuroma, or other conditions.1,16 Electrocardiography, Holter monitoring, or carotid Doppler testing may be performed if the clinical picture is suggestive of cardiovascular disease.1 Magnetic resonance angiography may be used if vertebrobasilar insufficiency is suspected.2 There are additional evaluation considerations for many differential diagnoses of dizziness beyond the scope of this article.
Pharmacologic options. Treatment depends on the underlying vertigo cause. Pharmacologic therapy that may be used for some causes of vertigo includes vestibular suppressants and antiemetics. Overall, medications have a more limited role in many cases of vertigo, and the recommended duration of use is usually short.5 Vestibular suppressants include antihistamines, benzodiazepines, and anticholinergics.19 Antihistamines with anticholinergic properties may be considered for vertigo symptoms, including meclizine, diphenhydramine, and dimenhydrinate.19,30 Benzodiazepines, such as lorazepam, diazepam, and clonazepam, may be considered for symptoms in some cases.1,19,30 Scopalamine is an anticholinergic that increases motion tolerance.19 Examples of antiemetics that may alleviate nausea and vomiting are promethazine (which also has antihistamine properties), metoclopramide, prochlorperazine, and ondansetron.30
There are potential risks associated with medications used for vertigo. Though not an exhaustive list, some important adverse reactions include drowsiness, cognitive deficits, interference with driving or operating machinery, and increased risk of falls.1,19 Caution is highlighted with benzodiazepines because of their adverse event profile and potential for dependence.2,5 In addition, benzodiazepines are not recommended for older adults, according to the American Geriatrics Society's 2019 Beers criteria.31 One of the most significant issues with the use of vestibular suppressants (antihistamines and benzodiazepines) for dizziness is their interference with central compensation, which can prevent recovery and prolong vertigo symptoms.1,19
BPPV. Fortunately, there are effective treatment options for BPPV, which is important because this common condition can have significant quality-of-life implications.19 Treatment options for BPPV include watchful waiting, particle repositioning maneuvers, vestibular rehabilitation, and rarely surgery for refractory cases.2,11,19 Pharmacologic therapy has less of a role in BPPV.
BPPV often responds very well to canalith repositioning maneuvers (CRP), such as the Epley maneuver, and there are strong recommendations for its use.1,19 The success rate of Epley maneuver is approximately 70% on the first attempt and nearly 100% on successive maneuvers.1 Adverse reactions from CRP are uncommon, but it is important to inform patients that nausea, vomiting, or a sense of falling may occur during the maneuver.19 Primary care NPs can learn to perform CRP.11,19 The Epley maneuver is a five-step CRP process.1 It is recommended that patients follow up within a month to document resolution or persistence of symptoms.19 Another treatment option is the liberatory (or Semont) maneuver, which has been shown to have similar efficacy to the Epley maneuver.19 BPPV affecting the lateral semicircular canal is less common than BPPV of the posterior canal and uses different techniques for diagnosis (supine roll test) and treatment (Lempert roll or Gufoni maneuvers).19 Lateral canal BPPV can also occur after CRP for posterior canal BPPV.19
There is also a home version of the Epley maneuver that patients with BPPV can even perform themselves prior to contacting the NP.
Healthcare providers should consider caution before performing any of these maneuvers if a patient has vascular disease (risk of stroke or vascular injury), back, spinal and cervical conditions, Down syndrome, severe rheumatoid arthritis, obesity, and Paget disease.19 Additional evaluation, resources, and assistance may be needed in these patients with these dual diagnoses.19 A referral to an otolaryngology healthcare provider is recommended if the primary care NP does not feel confident treating BPPV with these maneuvers, is unsure about the diagnosis or results of testing, or any of the above cautions is present.11,19
Medications have not been shown effective in the treatment of BPPV and may offer more harm than benefit.19 Some sources state there is no role for pharmacologic treatment for BPPV and recommend avoiding vestibular suppressant medications because of their interference with central compensation.1,11,19 A guideline made a specific recommendation for avoidance of vestibular suppressants, such as antihistamines and benzodiazepines, for routine use in BPPV, but suggested they may be used short-term for severe symptoms of nausea or vomiting as an adjunct to CRP.19
Ménière disease. Ménière disease may improve with a low-salt diet, thiazide diuretic, reducing caffeine intake, and limiting alcohol consumption to no more than one drink per day.1 Brief use of a vestibular suppressant may be indicated for an acute attack.1,22 Vestibular exercises or vestibular rehabilitation may be recommended and surgery may be needed in rare refractory cases.1 A referral to an otolaryngology provider is recommended for Ménière disease.
Vestibular neuritis. Vestibular neuritis is a self-limiting condition and as inflammation resolves, vertigo symptoms subside.14 Reassurance and education are recommended, in combination with symptomatic treatment, such as a vestibular suppressant for the first 1 to 2 days.1 The duration of these medications is limited to 2 days because of their effects in blocking central compensation.1 Vestibular rehabilitation may also be recommended, which may enhance long-term recovery.1,14 Insufficient evidence for the routine use of systemic corticosteroids exists for this condition.1
Vestibular migraine. Initial management of vestibular migraine focuses on identifying and avoiding migraine triggers and stress relief, as well as getting adequate sleep and exercising.1 Short-term treatment with a vestibular suppressant medication may be considered.1 Prophylactic medications may be considered in some cases to try to reduce the frequency of attacks.1
Referral. Although much can be done in primary care for many patients with vertigo, referrals may be indicated for a variety of reasons. Indications for referral for dizziness include unclear diagnosis, suboptimal or unexpected treatment response, concerning neurologic or cardiovascular findings, or other serious underlying disorder.2,5,19 Serious cases with red flags warrant urgent evaluation and may require hospitalization.5
Several considerations regarding otolaryngology referral have been discussed; for example, hearing loss that is associated with dizziness. They can further evaluate any type of hearing loss and perform audiometry.10 However, if the hearing loss is sudden, an urgent otolaryngology referral is recommended since treatment success is related to early initiation of treatment.32 Patients with vestibular dysfunction or disequilibrium may be referred to a physical therapist who can provide a valuable service with vestibular rehabilitation, which has been described as a prime intervention.5 Psychotherapy may help psychogenic causes of dizziness.8
Patients with dizziness or vertigo need to be cautious, as potential injury can occur. A decrease in rapid movements is important to reduce the likelihood of falls. Falling is a concern for older adults with these symptoms. In addition, patients experiencing dizziness should not drive a car or operate heavy machinery.5 Patients with vertigo and risk factors for stroke should be evaluated promptly. Patients also need to seek swift care if they have dizziness and associated chest pain, syncope, double vision, and/or onset of severe headache.5,8,11
As long as the patient does not have any of the signs associated with life-threatening conditions, trialing the Brandt-Daroff exercises at home can potentially improve BPPV symptoms without a need for a clinic visit.1 Like the Epley maneuver, these exercises can cause nausea. If these exercises cause any other associated symptoms or if symptoms do not improve at home, then further evaluation is warranted.
Dizziness has the potential to be chronic in nature. Primary care NPs and patients need to be aware of the standardized Patient-Reported Outcomes Measurement Information System (PROMIS) instruments to document symptoms and effects on patient function. PROMIS, a National Institutes of Health program, was initiated to help standardize the way patients self-report symptoms, specifically with chronic presenting symptoms and diseases. The tool for dizziness can be used by both the patient and NP to assess patient-reported outcomes. These tools help patients appreciate symptom improvement, link with treatments, and determine the need for modification. These tools can be completed in the office or at home and brought to the clinic visit by the patient.33
Dizziness is a challenging complaint to evaluate; however, a systematic approach can help narrow the vast list of differential diagnoses. The history and physical examination have particular value in sorting out dizziness and differentiating vertigo. Awareness of common causes, characteristics, and red flags is important. The primary care NP can manage many cases of dizziness, but some serious cases require referral for additional workup or treatment. It is prudent for primary care NPs to have a strong working knowledge of BPPV because it is so common. The Dix-Hallpike maneuver is a key examination technique for BPPV, and CRP with the Epley maneuver is often a very effective treatment. When the dizziness persists, the diagnosis remains unclear, or standard therapies do not produce expected results, other members of the healthcare team can assist primary care NPs in expanding the workup or advancing the treatment regimen so that optimal outcomes are facilitated for each patient.
Dizziness classifications with respective differential diagnoses1,2,5,7,8,10-14
- – most common cause of vertigo
- vestibular neuritis
- – second most common cause of vertigo
- Ménière disease
- vestibular schwannoma (acoustic neuroma)
- head trauma
- physiologic (motion sickness)
- otitis media
- – steroids (salt-retaining)
- – aminoglycosides
- – aspirin
- – furosemide (ototoxic)
- vestibular migraine
- brainstem or cerebellar dysfunction
- vertebrobasilar insufficiency
- stroke or transient ischemic attack
- brain tumor in posterior fossa
- multiple sclerosis
- central nervous system infection, such as neurosyphilis
- basilar migraine (migraine with brainstem aura)
- peripheral neuropathy (particularly feet), vitamin B12 deficiency
- Parkinson disease
- multisensory deficits (one cause: diabetes mellitus)
- vision disorders
- – alcohol
- – sedatives
- – antiepileptic drugs
Presyncope or syncope
- cardiac conditions (dysrhythmias)
- hypotension, orthostatic hypotension
- vasovagal reactions
- severe anemia
- psychogenic (psychiatric disorders)
- psychotropic drugs
- head trauma
- medication adverse reaction
Performing the Epley maneuver at home