Summary of a presentation made by Kevin Shi, MD, CCFP (EM), FCFP, at St. Paul’s Hospital during Balance Awareness Week 2017. Dr. Shi is an emergency physician at Delta and Richmond General Hospitals and a clinical associate professor at UBC. 

When a dizzy patient walks through their door, what is going through the mind of primary care physiciansFirst, they think about how to get a sense of what is causing the dizziness. They do this by listening to what the patient has to say.  In addition, doctors watch for “red flags” that might indicate a medical emergency.  

Primary care physicians will begin by asking the patient to describe their symptoms. One symptom is light-headedness  (feeling faint or about to pass out). A light-headed patient may also feel hot or cold, sweat, be pale or have palpitations. The causes of light-headedness can be classified into four categories: 

  • vasovagal (simple faint); 
  • cardiac (heart related); 
  • metabolic (low blood sugar, anemia, infection, dehydration or drugs); and 
  • brain (stroke or seizures)  this is the least likely cause of light-headedness. 

The second symptom is vertigo (spinning sensation). It often gets much worse if the head is moved and may be continuous or intermittent. There are two types of vertigo, known as central and peripheral, depending on where the cause is acting. 

Central vertigo originates in the brain. A patient with this symptom may be having a stroke and needs to get to an emergency department as soon as possible. 

Peripheral vertigo has its source in the balance organs of the inner ear. It may be a symptom of: 

  • BPPV (benign paroxysmal positional vertigo); 
  • Ménière’s disease; 
  • vestibular neuritis or labyrinthitis. 

The doctor will also be on the lookout for danger signs of a potentially serious problem
“Red flags” include fever, chest pain/heart racing or symptoms of a stroke. Stroke symptoms are treated as a medical emergency and include: headache; passing out; double vision; speech or swallowing problems; weakness in one arm or leg; and difficulty walking. 

Other “red flag” signs the doctor will consider are: 

  • persistent vertigo (lasting more than a few minutes); 
  • history of stroke; 
  • risk factors for stroke, such as diabetes and/or high blood pressure; and 
  • older patient. 

The doctor will do a physical exam – it may include checking the patient’s: 

  • vital signs (heart rate and blood pressure); 
  • gait; 
  • eyes – looking for involuntary eye movement (nystagmus); 
  • ears and hearing; and 
  • strength and reflexes. 

Special tests, such as a head impulse test or Dix-Hallpike maneuver, may also be done. 

Depending on the symptoms, the doctor may call for more investigation. This might include sending the patient for further tests such as: 

  • Blood (haemoglobin and blood sugar); 
  • CT (computerized tomography) scan of the head; or 
  • ECG (electrocardiogram). 

Treatment prescribed by the doctor will depend on what is wrong and usually falls into one of three categories: 

  • disease-specific management, for example: for stroke – prevention; for Ménière’s – medication; and for BPPV – rehabilitation exercises; 
  • symptomatic treatment to suppress the balance system, for example: antihistamines; benzodiazepines; or antiemetics (for nausea and vomiting); or 
  • exercise (vestibular rehabilitation therapy).