头晕的全科诊疗思路

朱莹; 任菁菁

doi:10.16766/j.cnki.issn.1674-4152.004235

头晕的全科诊疗思路

doi: 10.16766/j.cnki.issn.1674-4152.004235

朱莹,
任菁菁^,

浙江大学医学院附属第一医院全科医学科，浙江杭州 310003

基金项目:

国家自然科学基金项目 72274169

详细信息

通讯作者:
任菁菁，E-mail：3204092@zju.edu.cn

中图分类号: R499
计量
- 文章访问数: 13
- HTML全文浏览量: 11
- PDF下载量: 2
- 被引次数: 0
出版历程
- 收稿日期: 2025-04-29
- 网络出版日期: 2026-01-07

Diagnosis and treatment of dizziness: a general practice perspective

ZHU Ying,
REN Jingjing^,

Department of General Practice, the First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang 310003, China

摘要

摘要: 头晕是全科门诊的一种常见疾病，发病率和患病率高，影响着患者的身体、心理和社会健康。有研究表明，头晕可能会造成相关功能损害，导致跌倒风险增加12倍，严重影响患者的生活质量，甚至出现死亡。头晕症状涉及的疾病种类较多，病因相对复杂，首诊全科医生容易出现漏诊和误诊。因此需要培养全科医生运用全科思维习惯，规范化诊治头晕，提高鉴别诊断技巧。对于主诉为头晕的患者，全科医生通过RICE问诊的方式采集病史，进行详细的体格检查、有针对性的辅助检查，进行全面的综合评估，快速判断病情的急危重程度至关重要，识别出“红旗征”并及时转诊。全科医生的管理策略包含非药物治疗、药物治疗、康复治疗、心理治疗和随访等多方面治疗方案，同时发挥协调作用，将基层诊疗和综合医院转诊相结合，以期改善症状、降低功能损害、提高生活质量及减轻医疗负担。此外，目前我国缺乏评估头晕的完整体系，缺乏符合我国国情的头晕评估量表和标准化诊疗模型。全科医生如何诊断病因不明的头晕，如何帮助部分患者与症状共存，如何提供长期管理，尚待进一步研究。本研究总结归纳头晕的常见疾病、病情特点和诊疗方案，旨在为首诊全科医生规范化诊治头晕提供参考。
- 头晕 /
- 全科医生 /
- 诊治思路
Abstract: Dizziness is a common medically unspecified disease in general practice, with high incidence and prevalence, which affects patients ' physical, psychological, and social health at all times. A study found that dizziness may cause related functional damage, increase the risk of falls by 12 times, seriously affect their quality of life, and even lead to death. Dizziness involves a wide range of diseases with relatively complex causes, making it prone to missed diagnosis and misdiagnosis by general practitioners during initial consultations. Therefore, it is imperative to train general practitioners to adopt a holistic approach, standardize the diagnosis and treatment of dizziness, and improve the skills of differential diagnosis. For patients with complaints of dizziness, the general practitioner collects medical history through the RICE interview, conducts a detailed physical examination, targeted examination, and carries out a comprehensive evaluation. In particular, it is very important to quickly assess the degree of dizziness, identify the "red flag signs", and refer patients in time. The management strategies of general practitioners encompass non-pharmacological therapies, pharmacological interventions, rehabilitation programs, psychotherapy, and follow-up appointments, and play a coordinating role by combining primary diagnosis and treatment with referral to general hospitals, in order to alleviate symptoms, reduce functional damage, improve quality of life, and reduce medical burden. In addition, there is a lack of a complete system for evaluating dizziness in China, as well as an assessment scale and standardized diagnosis and treatment model that meet the national conditions of China. For general practitioners, how to diagnose dizziness with unknown causes, help some patients live with symptoms, and provide long-term management remains to be further researched. This article reviews the relevant domestic and foreign literature on dizziness, summarizes the common diseases, clinical characteristics, and diagnosis and treatment of dizziness, aiming to provide help for general practitioners to standardize the diagnosis and continued management of patients with dizziness.
- Dizziness /
- General practitioners /
- Diagnosis and treatment

HTML全文

图 1 头晕的诊断流程

注：TIA为短暂性脑缺血发作；HINTS检查：凝视诱发性眼震、头脉冲试验、眼偏斜；BPPV为良性阵发性位置性眩晕；PPPD为持续性姿势-感知性头晕。

Figure 1. The diagnostic process for dizziness

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表 1 根据不同发作形式和病变部位分类的头晕常见病因

Table 1. Common causes of dizziness based on lesion type and location

疾病分类	急性持续性	反复发作性	慢性持续性
前庭周围性头晕/眩晕	前庭神经炎	良性阵发性位置性眩晕	双侧前庭病
	突发性聋伴眩晕	梅尼埃病	中耳/颞骨/内耳道占位等病变
	急性中耳炎、迷路炎等	前庭阵发症
前庭中枢性头晕/眩晕	脑卒中	前庭性偏头痛	颅内占位性病变
	颅内感染性疾病	短暂性脑缺血发作	神经系统变性疾病
	脱髓鞘疾病等	癫痫等	颅颈交界区发育异常等
全身疾病相关性头晕	冠状动脉粥样硬化性心脏病	心律失常	药源性：高血压药、镇静剂
	急性发热性感染等	直立性低血压	眼源性
		药源性	全身系统疾病：贫血、出血、尿毒症
		颈源性：颈椎病、颈椎关节不稳	睡眠呼吸暂停综合征等
		晕动病等
精神心理性头晕	少见	惊恐发作等	持续性姿势知觉性头晕
			焦虑抑郁障碍
病因不明性头晕

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表 2 常见前庭周围性头晕/眩晕的临床特征及诊疗方案

Table 2. Common clinical characteristics, diagnosis, and management of peripheral vestibular dizziness/vertigo

常见疾病	临床表现	阳性体征	诊疗方案
良性阵发性位置性眩晕	1.突然出现短暂性眩晕；2.特定头位(起床或翻身时)诱发；3.可有恶心呕吐等症状	位置试验诱发眩晕及眼震，眼震特点符合相应半规管兴奋或抑制的表现	首选手法复位
前庭神经炎	1.常有上呼吸道感染史；2.持续时间长；3.常伴恶心、呕吐及身体不稳感等；4.无耳鸣及听力下降	自发性朝向健侧的水平扭转性眼震、站立时身体向患侧倾倒	激素治疗、康复训练
梅尼埃病	1.发作性旋转性眩晕；2.波动性、渐进性听力下降；3.伴有耳鸣或耳胀满感	波动性感音神经性听力损失、甘油试验阳性	1.发作期控制眩晕、对症治疗；2.间歇期预防复发，包括调整生活方式、口服倍他司汀和利尿剂、激素治疗、手术治疗等；3.前庭康复训练
前庭阵发症	1.发作性眩晕至少10次；2.持续时间少于1 min；3.症状刻板；4.伴站立或步态不稳	听觉脑干反应异常、自发性眼球震颤	卡马西平或奥卡西平
突发性聋	1.突发听力急剧下降；2.伴耳鸣；3.伴眩晕、恶心呕吐，不反复发作；4.单耳发作	Rinne/Weber试验：突发非波动性感音神经性听力损失	激素、血液稀释和改善循环、高压氧等治疗
双侧前庭病	1.仅行走或站立时出现不稳，夜间明显，可伴振动幻视；2.静坐或平躺时症状消失；3.慢性持续性症状	Romberg试验阳性	前庭康复训练

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表 3 常见前庭中央性头晕/眩晕的临床特征及诊疗方案

Table 3. Common clinical characteristics, diagnosis, and treatment of central vestibular dizziness/vertigo

常见疾病	临床表现	阳性体征	诊疗方案
后循环梗死(脑干和小脑为主)	急性发作性头晕/眩晕、肢体瘫痪或麻木、复视、构音障碍、饮水呛咳或吞咽困难、共济失调等	固视抑制试验失败、垂直性凝视性眼震、四肢肌力不对称、共济运动检查阳性等	内科对症治疗、溶栓治疗或血管内介入治疗等
脑干小脑出血	突发性头晕/眩晕，肢体瘫痪或麻木、共济失调，伴头痛、呕吐，重者昏迷等	脑干、小脑受累体征	内科对症治疗、手术治疗等
前庭性偏头痛	1.发作性的自发性眩晕; 2.持续5 min~72 h; 3.伴或不伴偏头痛; 4.可伴畏光惧声、视觉先兆等	发作间期无明显阳性体征，发作期可见眼球震颤	参考偏头痛的治疗或预防措施：1.急性期首选曲坦类药物；2.预防性治疗：钙离子拮抗剂、抗癫痫药物、β受体阻滞剂、抗抑郁药物等；3.前庭康复训练
颅内占位性病变	亚急性或慢性起病，头晕、肢体瘫痪和麻木、步态不稳，常有进行性耳鸣和听力下降	病变侧听力下降，构音障碍、共济失调等中枢损害的体征	手术治疗
颅内感染性疾病	急性起病，有发热、头痛等感染症状，有脑干和小脑损害等表现，可伴有眩晕	脑膜刺激征阳性、脑脊液检查	抗感染、激素、降颅压等治疗
癫痫	1.发作性旋转性眩晕，与体位无关; 2.眩晕突发突止; 3.可伴面色苍白、出汗、呕吐等	脑电图特异改变	病因治疗、抗癫痫治疗

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表 4 常见非前庭系统头晕的临床特征及诊疗方案

Table 4. Common clinical characteristics, diagnosis, and treatment of non-vestibular system dizziness

分类	常见疾病	临床表现	阳性体征	诊疗方案
全身疾病相关性头晕	直立性低血压	站立时将要摔倒的不稳感，可伴黑曚、视物模糊等，持续数秒至数十秒	直立倾斜试验阳性	对因治疗
	药源性眩晕	头晕/眩晕症状出现与药物使用呈锁时关系，常见于降压药、抗癫痫药、抗感染药等	无明显阳性体征	停药
	颈性眩晕	头晕或眩晕、颈部损伤症状	转颈试验阳性、颈部扭转眼球震颤试验	手法治疗、颈椎牵引、药物治疗等
	晕动症	乘坐交通工具时出现头晕，伴恶心呕吐、面色苍白、出冷汗等	无明显阳性体征	前庭抑制剂
精神心理性头晕	持续性姿势-感知性头晕	1.非旋转性头晕及不稳感持续3个月或以上，发作超过15 d/月；2.常在直立位或复杂的视觉环境中加重	无明显阳性体征	前庭康复训练、心理治疗
病因不明性头晕	病因不明	无特殊临床表现	无明显阳性体征	对症处理，随访观察

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表 5 头晕的红旗征及临床意义

Table 5. "Red flag" signs of dizziness and their clinical significance

红旗征	临床意义(可能性)
胸闷胸痛、意识障碍或晕厥	严重心律失常、急性冠脉综合征、后循环梗死
急性枕部疼痛持续存在	椎基底动脉夹层
急性发作伴神经系统受损的体征，如肢体活动障碍、构音障碍、面部感觉障碍等	后循环梗死、脑干小脑出血、脑膜炎、多发性硬化
急性发作伴高热、喷射性呕吐	颅内感染
精神症状	癫痫、精神疾病

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