What are the primary diagnostic tests for vertigo (dizziness) and lightheadedness?

From the Guidelines

The primary diagnostic tests for dizziness and giddiness include a comprehensive neurological examination, vestibular function tests, and imaging studies, with the Dix-Hallpike maneuver being the most important test for diagnosing benign paroxysmal positional vertigo (BPPV) 1. The evaluation should begin with a detailed history and physical examination to distinguish between vertigo, lightheadedness, disequilibrium, and presyncope.

• Specific tests include:
  • Dix-Hallpike maneuver to diagnose BPPV
  • Electronystagmography (ENG) or videonystagmography (VNG) to assess vestibular function
  • Audiometry to evaluate hearing loss that may accompany vestibular disorders
  • Caloric testing to identify unilateral vestibular weakness
  • Rotational chair testing to measure vestibulo-ocular reflex function
  • Video head impulse testing (vHIT) to evaluate semicircular canal function
• Laboratory tests should include:
  • Complete blood count
  • Metabolic panel
  • Thyroid function tests
  • Vitamin B12 levels to rule out systemic causes
• Brain imaging with MRI is recommended when central causes are suspected, particularly in patients with neurological symptoms, new-onset headaches, or risk factors for cerebrovascular disease 1.
• CT scans may be used when MRI is contraindicated or unavailable.
• For patients with recurrent unexplained dizziness, 24-hour Holter monitoring or longer-term cardiac event monitoring may be necessary to detect cardiac arrhythmias. The selection of tests should be guided by the clinical presentation, as different types of dizziness suggest different underlying pathologies 1. It is essential to note that the Dix-Hallpike maneuver is a strong recommendation for diagnosing BPPV, 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.

From the Research

Primary Diagnostic Tests for Dizziness and Giddiness

The primary diagnostic tests for dizziness and giddiness include:

• A systematic patient history and physical exam to accurately diagnose conditions related to dizziness 2
• Classification of dizziness into one of four categories: vertigo, disequilibrium, presyncope, or lightheadedness based on the patient history 3
• Physical examination tests, including:
  • Evaluation for nystagmus
  • The Dix-Hallpike maneuver
  • Orthostatic blood pressure testing 3, 4, 5
• The HINTS (head-impulse, nystagmus, test of skew) examination to help distinguish peripheral from central etiologies 4, 5
• A full cardiac and neurologic examination 4, 5

Laboratory Testing and Imaging

• Laboratory testing and imaging are usually not required and are often not helpful in diagnosing dizziness 3, 4, 5, 6
• However, they may be ordered for patients who have abnormal findings on physical examination that may indicate a more serious cause of dizziness 6

Treatment Options

• Treatment of dizziness is dependent on the etiology of the symptoms 4
• Canalith repositioning procedures (e.g., Epley maneuver) are the most helpful in treating benign paroxysmal positional vertigo 3, 4, 5
• Vestibular rehabilitation is helpful in treating many peripheral and central etiologies 4, 5