Initial Workup for a Patient Presenting with Dizziness

Characterization and Classification of Dizziness

The American Academy of Otolaryngology-Head and Neck Surgery recommends determining the timing, triggers, and associated symptoms to classify dizziness into one of four distinct vestibular syndromes, which will guide further evaluation and management 1
The initial workup should focus on characterizing the dizziness as true vertigo (sensation of rotation or spinning) versus non-specific dizziness (sensation of disturbed spatial orientation without false sense of motion) 2
Dizziness can be classified into four categories: acute vestibular syndrome, triggered episodic vestibular syndrome, spontaneous episodic vestibular syndrome, and chronic vestibular syndrome 1, 2, 3, 4

A focused history should include the duration of each episode, with brief episodes (seconds) suggesting BPPV, and longer episodes (minutes to hours) suggesting Ménière's, vestibular migraine, or other conditions 2, 1
The patient's history should also include triggers, such as positional changes, which may indicate BPPV or other peripheral vestibular disorders 1, 5
Associated symptoms, such as hearing loss, tinnitus, or aural fullness, may suggest Ménière's disease 6, while headache and photophobia may suggest vestibular migraine 2
A complete otologic examination, including nystagmus assessment and vestibular examination, is essential in the initial workup 2, 4

Laboratory testing, such as basic metabolic panel, complete blood count, and thyroid function tests, may be ordered if dehydration, electrolyte abnormalities, infection, or thyroid disorder is suspected 5
Imaging studies are generally not required in the initial workup unless neurological symptoms, atypical presentation, or red flags are present 2, 1, 4
Common diagnoses to consider include Benign Paroxysmal Positional Vertigo (BPPV), Vestibular Neuritis, Labyrinthitis, Ménière's Disease, and Vestibular Migraine 2, 1, 4, 6

Red flags requiring urgent evaluation include focal neurological deficits, sudden hearing loss, and inability to stand or walk 2
Common pitfalls to avoid include relying solely on the patient's description of "dizziness" without clarifying the exact nature of symptoms, and failing to perform the Dix-Hallpike maneuver and supine roll test in patients with positional symptoms 2, 7, 4