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Here is a structured summary of the UpToDate article "Approach to the Patient with Dizziness" (last updated July 2022, literature reviewed through January 2024):
Overview
"Dizziness" is a nonspecific complaint. The first clinical step is classifying it into one of four syndromes: vertigo, presyncope, disequilibrium, or nonspecific dizziness. History is the most powerful diagnostic tool; physical examination confirms rather than establishes the diagnosis.
Epidemiology of Causes
Across settings (primary care, ED, dizziness clinics):
- ~40% peripheral vestibular dysfunction
- ~15% psychiatric disorders
- ~10% central vestibular lesion
- ~25% other (presyncope, disequilibrium)
- ~10% unknown
Older adults have a higher rate of central causes (~20%), often stroke-related.
1. Vertigo
Vertigo arises from acute asymmetry in the vestibular system (inner ear, vestibular nerve, medulla, cerebellum). Patients describe it as an illusion of motion - spinning, whirling, or tilting - of themselves or their environment.
Key diagnostic features:
- Time course: Never truly continuous for more than a few weeks; "constant" dizziness for months is usually psychogenic
- Provoking factors: Worsened by head position changes (lying down, rolling over, looking up) without a drop in blood pressure - this distinguishes positional vertigo from orthostatic presyncope
- Aggravating factors: All vertigo worsens with head movement; if it doesn't, it's likely not vertigo
- Nystagmus: Presence strongly suggests vertigo; pathologic nystagmus is asymmetric or prolonged
Peripheral vs. Central Vertigo:
| Feature | Peripheral | Central |
|---|---|---|
| Nystagmus direction | Unidirectional, horizontal-torsional | Variable; may be purely vertical or torsional |
| Visual fixation | Suppresses nystagmus | Does not suppress |
| Postural instability | Mild, walking preserved | Severe, patient often falls |
| Hearing loss/tinnitus | May be present | Usually absent |
| Other neuro signs | Absent | Often present (diplopia, dysarthria, ataxia) |
Dix-Hallpike maneuver (sensitivity ~80% for BPPV): moving patient rapidly supine with head tilted 45° down and rotated 45°. In peripheral lesions, nystagmus has a 2-20 second latency, lasts <1 minute, and fatigues with repetition. In central lesions, onset is immediate, lasts >1 minute, and does not fatigue.
2. Presyncope
A near-faint sensation ("nearly blacking out"), typically lasting seconds to minutes. Associated symptoms: lightheadedness, warmth, diaphoresis, nausea, visual blurring. Bystanders often note pallor. Occurs almost exclusively in upright posture; if supine, suspect cardiac arrhythmia.
Common causes include orthostatic hypotension, vasovagal attacks, and cardiac arrhythmias. Evaluation mirrors the syncope workup.
3. Disequilibrium
A sense of imbalance primarily while walking. Often underreported - patients rarely volunteer it; gait observation and neuro exam are needed to identify it. Common causes:
- Peripheral neuropathy
- Parkinson disease (also has postural hypotension)
- Cerebellar disease (associated dysarthria, gaze-evoked nystagmus)
- Cervical spondylosis
- Visual impairment
4. Nonspecific Dizziness
Hard to characterize; patients may endorse multiple descriptor types simultaneously. Key considerations:
- Psychiatric: 25% major depression, 25% generalized anxiety/panic disorder, remainder somatization/alcohol/personality disorders. CBT combined with vestibular rehabilitation shows short-term benefit.
- Hyperventilation: Dizziness that builds gradually and waxes/wanes over 20+ minutes; can be reproduced intentionally in the office. Watch for nystagmus during hyperventilation - if present, vestibular lesion is the cause, not hyperventilation.
- Medications: Antidepressants, anticholinergics, drug withdrawal
- Other: Hypoglycemia, post-head trauma/whiplash, milder forms of vertigo or presyncope
5. Dizziness in Older Patients
Prevalence up to 38% in some series; major risk for falls, disability, and institutionalization. Often multifactorial - one study found 44% of patients aged 65-95 had more than one contributing cause.
Seven independent risk factors (Tinetti et al.):
- Anxiety trait
- Depressive symptoms
- Impaired balance
- Prior myocardial infarction
- Postural hypotension (BP drop ≥20%)
- Five or more medications
- Impaired hearing
Drug side effects contribute to dizziness in 20-25% of older patients. In this population, presyncope-type dizziness predominates (69%), with cardiovascular disease as the most common contributing factor (57%).
Bottom Line (from the article's own summary)
- History classifies dizziness; physical exam confirms it
- Vertigo: illusion of motion, worsened by head movement, associated with nystagmus
- Presyncope: impending-faint sensation, upright posture, pallor
- Disequilibrium: imbalance while walking; look for neuropathy, parkinsonism, cerebellar disease
- Nonspecific dizziness: broad differential including psychiatric causes, medications, metabolic, and mild forms of the above
- Older patients: expect multiple concurrent causes and a medication review
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I now have enough content to provide a thorough summary. Here it is:
Summary: "Evaluation of Headache in Adults" (UpToDate, last updated March 2023)
Classification of Headaches
Primary headaches account for the vast majority of cases. The three main types are:
| Type | Key Features |
|---|---|
| Migraine | Recurrent attacks, often unilateral, throbbing/pulsatile; associated with nausea, photophobia, phonophobia, osmophobia; worsened by activity |
| Tension-type (TTH) | Mild-to-moderate, bilateral, non-throbbing, featureless; may involve neck and jaw; no nausea or photo/phonophobia |
| Cluster headache | Severe, unilateral; ipsilateral autonomic symptoms (ptosis, lacrimation, rhinorrhea, conjunctival injection); lasts 15-180 min; patient is restless |
- Episodic TTH is the most common in the population, but migraine is the most common diagnosis seen in clinical practice.
- Cluster headache has a low prevalence (<1%) but causes significant disability.
Secondary headaches have an identifiable underlying cause (fever, hypertension, sinusitis, neoplasm, vascular lesion, etc.). In Brazilian primary care, 39% of headache patients had a systemic cause and 5% had a neurologic cause.
Evaluation Approach
History is the single most important diagnostic tool. A systematic history should cover:
- Age at onset, prior headache history, any recent pattern change
- Frequency, intensity, duration, number of headache days/month
- Time and mode of onset, quality and location of pain
- Aura/prodrome, associated symptoms, family history of migraine
- Triggers, positional changes, effect of activity
- Medications (including overuse), menstrual relationship, recent stressors/trauma
Physical exam should include blood pressure, pericranial/neck muscle palpation, temporal artery palpation, and a full neurologic exam (mental status, cranial nerves, fundoscopy, motor/reflex/coordination/sensory, gait).
Identifying Migraine: Screening Tools
ID Migraine (mnemonic: PIN) - positive if 2 of 3 answers are yes:
- Photophobia: did light bother you?
- Incapacity: did headache limit your ability to function for ≥1 day?
- Nausea: did you feel nauseated?
- Sensitivity 84%, specificity 76%; a positive screen raises migraine probability from 59% to 84%.
Brief headache screen: presence of episodic disabling headache correctly identifies migraine in ~93% of cases with episodic migraine.
Low-Risk Features (No Imaging Needed)
All of the following must apply:
- Age ≤50 years
- Typical features of a primary headache
- History of similar prior headache
- Normal neurologic exam
- No change in usual headache pattern
- No high-risk comorbidities
- No new or concerning findings
Danger Signs ("Red Flags") - Mnemonic SNNOOP10
Any of these warrants imaging (MRI or CT):
- Systemic symptoms (fever)
- Neoplasm history
- Neurologic deficit or decreased consciousness
- Onset sudden/abrupt (thunderclap)
- Older age (onset >50 years)
- Pattern change or recent new headache
- Positional headache
- Precipitated by sneezing, coughing, or exercise
- Papilledema
- Progressive or atypical presentation
- Pregnancy/puerperium
- Painful eye with autonomic features
- Post-traumatic headache
- Pathology of immune system/immunosuppression
- Painkiller overuse (analgesics, ergots, triptans)
Emergent Evaluation Triggers
These require immediate ED referral:
- Thunderclap headache (max intensity within 1 minute) - must rule out subarachnoid hemorrhage
- Neck pain + Horner syndrome ± neurologic deficit - suspect cervical artery dissection
- Fever + altered mental status ± nuchal rigidity - suspect meningitis/encephalitis
- Focal deficit or bilateral papilledema - suspect raised intracranial pressure
- Periorbital/orbital symptoms - suspect glaucoma, cavernous sinus thrombosis, or tumor
- Possible carbon monoxide exposure
Neuroimaging Selection
- Emergency: CT is preferred (fast, widely available, highly sensitive for hemorrhage)
- Non-emergency: MRI is preferred (more sensitive than CT, no radiation)
- LP is indicated if CT is negative but subarachnoid hemorrhage is still clinically suspected, or for suspected infection/inflammation/pseudotumor cerebri
- Routine imaging is not warranted in chronic stable headache with normal neuro exam (<1% yield for treatable lesions)
- Incidental findings on MRI occur in 1-2% and require careful patient counseling
Special Populations & Scenarios
- Older patients (>50): Higher risk for giant cell arteritis, trigeminal neuralgia, subdural hematoma, herpes zoster, hypnic headache, brain tumor - lower threshold for imaging
- Pregnancy: Rule out pre-eclampsia (in all patients >20 weeks), cerebral venous thrombosis; MRI without contrast preferred
- Sinus headache: Commonly misdiagnosed - 88% of patients with clinician/self-diagnosed "sinus headache" actually meet criteria for migraine. True sinus headache is bilateral, pressure-like, associated with fever and purulent discharge, without nausea/photo/phonophobia
- Post-traumatic headache: Occurs in 25-78% after mild TBI; usually resembles migraine or TTH
- Chronic daily headache (≥15 days/month for >3 months): Subtypes include chronic migraine, chronic TTH, medication overuse headache, hemicrania continua, and new daily persistent headache
Common Misconceptions
- "Sinus headache" is usually migraine
- Eye strain alone rarely causes headaches
- Hypertension does not cause typical migraine or TTH (only hypertensive emergencies cause headache); studies show high BP may actually be associated with reduced risk of nonmigrainous headache
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