15 - Dizziness and Vertigo

Abstract

Dizziness and vertigo are common complaints presenting to the emergency department (ED). There has been a recent movement away from the historical categorization of dizziness based on symptoms towards one that relies on timing and triggers. Benign paroxysmal positional vertigo (BPPV) remains the most common cause of vertigo. This is diagnosed via the Hallpike test and treated with the Epley maneuver, both of which can be performed at the patient’s bedside. Vestibular neuritis is another common cause of peripheral vertigo in the ED and is diagnosed via history and a positive head impulse test. It is important to apply diagnostic tests in the appropriate setting. For example, applying a head impulse test to a patient with BPPV will result in a negative test, and a negative head impulse test implies a potential central cause of vertigo and could lead to additional unnecessary tests. Associated neurologic symptoms such as imbalance, gait instability, dysarthria, or numbness are concerning for posterior circulation transient ischemic attack and stroke, although dizziness and vertigo may be the only initial symptoms. In such cases, diagnostic testing may be guided by an assessment of risk based on the history, risk factors, and physical examination. Certain patterns of nystagmus, such as purely vertical, downbeating, direction changing with gaze, and spontaneous pure torsional, are also more concerning for central causes of vertigo. Reassessment of neurologic findings and assessment of response to therapy are encouraged to help ensure that symptoms are not of central origin.