Dizziness and Vertigo _________________________________________________________________________
Review of systems should seek symptoms of causative disorders, including upper respiratory infection symptoms (inner ear disorders); chest pain and palpitations (cardiovascular disease); dyspnea (pulmonary disease); dark stools (anemia from GI blood loss); and weight change and heat or cold intolerance (thyroid disease) [11]. Past medical history should note recent head trauma (usually obvious by history), migraine, diabetes, heart or lung disease, and regular or daily drug and alcohol use. Identify all current medications, including recent changes in drugs, dosages, or both [11]. After major medical and other etiologies are ruled out, patients with dizziness or vertigo, with or without associated headache, otologic, autonomic, or balance symptoms, should receive a timing and triggers evaluation [36]. TIMING Timing refers to the onset, duration, and evolution of the diz- ziness attacks. Narrow the differential diagnosis by classifying the pattern of dizziness attacks as episodic, acute, or chronic in duration by defining the following [36; 103]: • Onset of dizziness attacks: Sudden or gradual and ill-defined • Duration of dizziness attacks (minimal and maximal): Seconds to minutes, several minutes to hours, or several hours to days • Evolution of dizziness attacks: ‒ Episodic dizziness lasting seconds to minutes, several minutes to hours, or several hours to days ‒ Acute with symptoms lasting days to weeks ‒ Persisting symptoms more than three months (chronic) TRIGGERS Almost all patients with vertigo feel worse with head move- ments. The critical distinction is whether head movements trigger (symptoms appear only when provoked by movements) or exacerbate (movements worsen pre-movement vertigo) symptoms [8; 19]. Head movement usually exacerbates dizziness/vertigo of any vestibular cause (benign or dangerous, central or peripheral), but the worsened dizziness is often conflated with a triggered peripheral cause, potentially missing a serious or life-threaten- ing central etiology [6; 8; 36].
The timing and triggers history of the TiTrATE algorithm divides patients into six vestibular syndrome categories [8; 36]: • Acute vestibular syndrome (AVS) ‒ Postexposure (traumatic/toxic) (t-AVS) ‒ Spontaneous (s-AVS) • Episodic vestibular syndrome (EVS) ‒ Triggered (t-EVS) ‒ Spontaneous (s-EVS) • Chronic vestibular syndrome (CVS) ‒ Context-specific (t-CVS) ‒ Spontaneous (s-CVS) In this context, “vestibular” refers to vestibular symptoms and not etiology. Vestibular symptoms include vertigo, dizziness, nausea, vomiting, and nystagmus [48]. The large differential diagnosis of potential dizziness etiologies is daunting to many clinicians. Triage-TiTrATE-Test greatly streamlines this process such that every forward step eliminates potential etiologies, substantially narrows the range, and by the final step, an accurate diagnosis is already evident or confirmed by referral for specialized testing [8]. This differential diagnosis process has been referred to as a funnel approach [36]. TRIAGE Some patients with a primary symptom of dizziness have obvi- ous associated symptoms (e.g., gastrointestinal bleeding) or context (e.g., new antihypertensive medications, anticonvulsant toxicity), abnormal vital signs, altered mental status, and/or ancillary test results that usually point to a likely diagnosis. These potential medication, toxicity, metabolic, cardiac, or psychiatric etiologies of dizziness are examined and patients are treated or referred for further evaluation as needed [10; 36]. Other dizziness, medical, and major neurologic etiologies lack prominent associated features, but can be ruled out by assessing [19]: • Neurologic history • Recent viral or bacterial infection • Patient medication list • Social history for alcohol and substance use • Psychiatric history Important associated symptoms to note include headache, hearing loss, tinnitus, nausea and vomiting, impaired vision, focal weakness, and difficulty walking. The severity of impair- ment should be assessed by asking about impact on work, driving, and recreational and social functioning [11].
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