A Referring Provider's Guide to Chronic Dizziness

Patients with >3 months subjective dizziness may need specialty referral.

Referring providers should consider a variety of causes of dizziness prior to referral for vestibular evaluation. These conditions include the following:

• Medications (i.e., central depression or ototoxicity)
• Cardiovascular disease; cardiac arrhythmias
• Metabolic disease (e.g., hypoglycemia)
• Gait issues, impaired proprioception, and/or peripheral neuropathy
• Orthostatic dizziness or lightheadedness

Process for Further Evaluation:

1. Audiometry and vestibular testing should be performed before the patient is seen by neuro-otology/ENT or neuro-ophthalmology/neurology to assist in triage.
2. Otolith repositioning will  be attempted if indicated by history or exam.
3. Orthostatic vital signs should be performed in cases in which dizziness is worse with standing.

Generally, testing results fall into one of several categories of findings. 

1. Unilateral or asymmetric hearing loss, or peripheral vestibular findings
   • The patient should see ENT/neuro-otology first.
2. Central findings suggesting brainstem or cerebellar pathology (downbeat nystagmus, direction changing gaze-evoked nystagmus) 
   • The patient should see neuro-ophthalmology/neurology first.
3. Normal VNG or minor central findings or abnormal VNG not explaining symptoms in setting of episodic or chronic vertigo
   • No migraine: proceed with algorithm for PPPD/3PD.
   • Migraine: proceed with algorithm for vestibular migraine.
4. Abnormal orthostatic vital signs
   • Chronic Orthostatic Intolerance (OI):
     1. Symptoms during standing without meeting criteria for POTS or OH, present for >3 months
     2. Most common subtype of autonomic dysfunction—symptoms increase in standing and improve/resolve with lying down
   • Postural Tachycardia Syndrome (POTS):
     1. >30bpm increase sustained during standing x 5–10 minutes (>40bpm if <19 years old) OR sustained HR >120bpm AND no significant drop in blood pressure (BP)
     2. Symptom provocation in standing, present for >3 months
   • Orthostatic Hypotension (OH):
     1. Sustained drop in BP; >20mmHg systolic, >10mmHg diastolic
     2. Often will have an increase in heart rate; if so, review medications, hydration, metabolic function, etc.
     3. If heart rate does not increase significantly AND patient has other signs and symptoms of neurological disease (movement problems, neuropathy), patient should see neurology and/or consider autonomic testing referral.