Management of dizziness in primary care

We sought to determine the types of dizziness problems that are commonly seen in primary care practices, and to bring to light clinical and demographic factors that predict management decisions.

We undertook a prospective cohort study with a 6-month follow-up using data gathered in nine primary care practices in two North Carolina counties. Subjects were 144 dizziness patients examined by primary care physicians. Data collected included demographic characteristics, a standardized dizziness history, physician estimation of symptom severity and diagnostic certainty, and physician "worry" about arrhythmia, transient ischemic attack, and brain tumor. Physicians reported their management decisions and diagnosis (or differential diagnosis) by responding to a questionnaire after completing the patient encounter. A 6-month follow-up chart review and physician interview were completed on 140 patients (97.2 percent); information obtained included changes in diagnosis and patient mortality.

The most common diagnoses were labyrinthitis, otitis media, benign positional vertigo, unspecified presyncope, sinusitis, and transient ischemic attack. The initial diagnosis changed during the 6-month follow-up period in 34 (24.3 percent) of patients. The overall course of these patients was benign, however, with only one death occurring during the 6-month follow-up period. Patients' dizziness tended to be managed using a combination of strategies, including office laboratory testing (33.6 percent), advanced testing (11.4 percent), referral to a specialist (9.3 percent), medication (61.3 percent), observation (71.8 percent), reassurance (41.6 percent), and behavioral recommendations (15.0 percent). Office laboratory testing was associated with younger patient age, a suspected metabolic or endocrine disorder, and physician worry about a cardiac arrhythmia; advanced laboratory testing was associated with suspected cardiovascular or neurologic disorders. Medication tended to be prescribed for vertigo and severe symptoms and avoided when physicians were worried about a cardiac arrhythmia. Referral to a specialist was associated with suspected neurologic disease. Observation, behavior change, and reassurance were avoided in patients with poorly defined dizziness and tended to be used in older patients. The management approaches employed by the 4 physicians who referred the most subjects to the study varied considerably.

Dizziness in primary care represents an extremely broad spectrum of diagnoses. The generally conservative management approach of primary care physicians in this study is consistent with basic clinical and epidemiologic principles, and patient mortality with this approach is low.