Appendix
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Internal Medicine

Evaluation of the Dizzy and Unbalanced Patient

Dizziness as a patient complaint can refer to many different sensations, including lightheadedness, vertigo, or unsteadiness. Dizziness is a common presenting complaint in ambulatory and emergency room settings and often progresses to inpatient care. It has commonly been separated into categories: vertigo, presyncope, lightheadedness, and disequilibrium. Unfortunately, it is rarely clear-cut, and patients often have difficulty distinguishing their symptoms. This activity outlines the differentia

v1 · Reviewed Nov 8, 2026 by Automated Clinical Reviewer (Strict Verbatim v1)
  • When evaluating a dizzy/unsteady patient, it is essential to remember that their symptoms could be secondary to a Cerebellar or Brainstem stroke
  • Associated symptoms that would suggest a central (neurologic) etiology, such as dysarthria, dysphagia, diplopia, truncal ataxia, or cerebellar signs.
  • Associated signs and symptoms may suggest a cardiovascular etiology, such as chest pain, arrhythmia, dyspnea, or orthostatic blood pressure changes.
  • Frank hypotension
  • Point of care glucose testing and an EKG should be performed on all dizzy and unbalanced patients.
  • The HINTS exam is a bedside test that can help distinguish between central and peripheral causes of vertigo and dizziness.
  • If there is clinical concern for a central neurologic cause for symptoms, a patient should undergo a non-contrast head CT, CTAs of the head and neck, and an MRI of the head.
  • Orthostatic hypotension (defined as blood pressure drop from sitting to standing: systolic blood pressure decrease of 20 mm Hg or a diastolic blood pressure decrease of 10 mm Hg)
ABCD2 score
part of the TITRATE algorithm to identify features suggestive of brain ischemia.
  • Benign Paroxysmal Positional Vertigo may be treated with medications (such as meclizine), the Epley maneuver, or vestibular rehabilitation.
  • Vestibular neuritis can be treated with supportive care with antiemetics and vestibular suppressants such as antihistamines, benzodiazepines, or dopamine antagonists.
  • Vestibular migraines are often managed with reassurance and lifestyle modifications; however, at times, prophylactic medications are required, such as metoprolol, amitriptyline, topiramate, valproic acid, or flunarizine.
  • Orthostatic Hypotension can be improved by increasing water intake, reviewing the medication list, making lifestyle changes, and, in some cases, adding Midodrine or a mineralocorticoid to the patient's medication regimen.
  • Meniere disease is typically treated with diuretics and salt restriction.
  • An otolaryngologist may treat Severe cases with intratympanic dexamethasone or gentamicin or endolymphatic sac surgery.
  • Superior canal dehiscence requires surgical intervention.
  • Idiopathic Perilymphatic fistulas are treated conservatively by avoiding activities that increase inner ear and intracranial pressure.
  • The most considerable complication of dizziness is secondary injury.
  • Dizziness and difficulty with balance are closely linked with a greater risk of falls.
  • Unfortunately, older individuals more commonly suffer from dizziness, and older individuals are also more likely to suffer severe injuries from falls.
  • Dizziness may also impair their ability to function independently and perform their activities of daily living.
  • review
    Evaluation of the Dizzy and Unbalanced Patient. StatPearls [Internet] — Alexis J. Davis, Alexander Pozun — StatPearls Publishing, 2023

Decision support only. Verify against local protocols and current labeling. Source: www.ncbi.nlm.nih.gov