What are the diagnostic investigations for vertigo (dizziness)?

From the Guidelines

The investigation for vertigo should begin with a detailed history and physical examination to distinguish between peripheral and central causes, with key tests including the Dix-Hallpike maneuver to identify benign paroxysmal positional vertigo (BPPV) 1. The Dix-Hallpike maneuver is a crucial test for diagnosing BPPV, which is the most common inner ear problem and cause of vertigo 1. The diagnosis of BPPV is based on the clinical history and physical examination with a positive result on the Dix-Hallpike test, and clinicians should not obtain radiographic imaging in a patient who meets diagnostic criteria for BPPV in the absence of additional signs and/or symptoms inconsistent with BPPV that warrant imaging 1. Some key points to consider in the investigation of vertigo include:

• The use of the HINTS examination to distinguish between peripheral and central causes of vertigo 1
• The importance of assessing patients with BPPV for factors that modify management, including impaired mobility or balance, central nervous system disorders, a lack of home support, and/or increased risk for falling 1
• The role of vestibular function tests, such as electronystagmography (ENG) or videonystagmography (VNG), in assessing eye movements and vestibular responses 1
• The indication for brain imaging with MRI when central causes are suspected, particularly with neurological symptoms, persistent vertigo, or risk factors for cerebrovascular disease 1
• The importance of referral to otolaryngology or neurology specialists for recurrent or severe cases 1. Overall, the investigation pathway should be guided by the pattern of symptoms, with peripheral vertigo typically presenting as brief episodes with associated hearing changes, while central vertigo often has a more gradual onset with additional neurological symptoms 1.

From the Research

Investigation for Vertigo

The investigation for vertigo typically involves a combination of medical history, physical examination, and diagnostic tests.

• The diagnosis of benign paroxysmal positional vertigo (BPPV) can be established through a Dix-Hallpike maneuver for the posterior and anterior canals, or supine roll test for the horizontal canal 2.
• The Dix-Hallpike test is a positioning nystagmus test used for diagnosis of posterior-canal-type BPPV, while the head roll test is a positional nystagmus test used for diagnosis of lateral-canal-type BPPV 3.
• The sensitivity and specificity of the Dix-Hallpike test have been estimated to be 79% and 75%, respectively, while the side-lying test has an estimated sensitivity of 90% and specificity of 75% 4.

Diagnostic Approach

A practical approach to diagnosing the cause of vertigo involves:

• Categorizing dizziness into one of the four groups: lightheadedness, pre-syncope, disequilibrium, and vertigo 5.
• Differentiating central vertigo from peripheral vertigo, with the most common cause of peripheral vertigo being BPPV 5.
• Using the tempo of the vertiginous attacks and other associated symptoms to help differentiate other causes of peripheral vertigo, such as Meniere's disease, vestibular neuronitis, labyrinthitis, and a perilymph fistula 5.

Treatment Options

Treatment options for BPPV include:

• The Epley maneuver, a canalith repositioning procedure (CRP) that involves a series of head movements to move the otoconial debris in the semicircular canal to the utricle 3, 6.
• Vestibular rehabilitation, which has been compared to the Epley maneuver in terms of effectiveness, with inconsistent evidence for the effectiveness of the Epley maneuver compared to vestibular rehabilitation at 1-month follow-up 6.