CARE: A differential diagnosis for dizziness

We’ve all been there; you look at your schedule and see a patient with a chief complaint of “dizziness.” Cue the sense of dread! 

While dizziness is a common symptom, its characteristic vagueness makes it the least favorite chief complaint of most clinicians. Most dizzy patients aren’t even sure how to accurately describe the sensation they’re feeling, so dizziness could mean presyncope, lightheadedness or true vertigo. And the differential diagnoses for this non-specific complaint are long and range from very benign to life threatening. Read on to learn some helpful acronyms to remember the broad differential diagnosis for dizziness.

The CARE Acronym
Differential diagnosis for dizziness can be broken broken down by etiology: 

(Note: this is not an exhaustive list, but rather a list of the most common things causes of dizziness. Also note that many of these are rare. Have we mentioned yet dizziness is complicated?)

• Peripheral -  BPPV, vestibular neuritis, labyrinthitis, Meiere’s disease, otosclerosis

• Central - Vestibular migraine, stroke/TIA, CNS bleed, vertebral artery dissection, tumors (acoustic neuroma) 

• Other - Medication-induced, psychiatric, arrhythmias, orthostatic hypotension, Parkinson’s disease, symptomatic anemia, toxicological process

You can then organize your differential using the CARE acronym, like so:

The TiTrATE Acronym

Another way to remember differentials for dizziness is to look for timing and triggers. TiTrATE is an acronym that can be used to help clinicians organize the differentials and make an accurate diagnosis based on the Timing of the symptoms, Triggers that provoke symptoms, And Targeted physical Exam.

Timing: Episodic or continuous? 

• Episodic: Commonly peripheral

• Continuous: Possibly central, could be vestibular neuritis or labyrinthitis 

Triggered:  Triggered or spontaneous?

• Episodic + triggered → BPPV, orthostatic hypotension

• Episodic + spontaneous → Meniere’s, vestibular migraine, psychiatric

• Continuous + triggered → medications, trauma

• Continuous + spontaneous → CV disease, tumors, vestibular neuritis or labyrinthitis 

Targeted Physical Exam:

• Focus on HEENT and neurologic exam

• Special tests: 

  • Dix Hallpike to Diagnose BPPV Dizziness for episodic, triggered vertigo to rule in BPPV

  • The HINTS exam for continuous vertigo to check for a central etiology

I hope these acronyms help you remember the broad differential diagnosis for dizziness and help take away some of the dread the next time you see “dizzy” on your schedule!