What is the diagnostic workup for vertigo (dizziness)?

From the Guidelines

The workup for vertigo should begin with a detailed history and physical examination to distinguish between peripheral and central causes, including a neurological examination, assessment of nystagmus characteristics, and provocative tests like the Dix-Hallpike maneuver for benign paroxysmal positional vertigo (BPPV) 1.

Key Components of the Workup

• A neurological examination to assess for signs of central nervous system involvement
• Assessment of nystagmus characteristics to help differentiate between peripheral and central causes
• Provocative tests like the Dix-Hallpike maneuver to diagnose BPPV
• Laboratory tests, such as complete blood count, metabolic panel, thyroid function tests, and vitamin B12 levels, to rule out metabolic causes
• Audiometry testing to evaluate for Meniere's disease or acoustic neuroma

Imaging and Vestibular Function Tests

• Imaging studies, such as MRI, are indicated when central causes are suspected, to better visualize posterior fossa structures 1
• Vestibular function tests, such as electronystagmography (ENG) or video head impulse test (vHIT), can help assess vestibular system function

Treatment and Management

• For suspected BPPV, the Epley maneuver can be both diagnostic and therapeutic 1
• Additional tests, such as videonystagmography, rotary chair testing, and vestibular evoked myogenic potentials, may be necessary depending on clinical presentation
• 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
• Clinicians should not order vestibular testing in a patient who meets diagnostic criteria for BPPV in the absence of additional vestibular signs and/or symptoms inconsistent with BPPV that warrant testing 1

From the Research

Work-up for Vertigo

The work-up for vertigo involves a thorough clinical assessment to determine the underlying cause of the symptoms. The following steps are involved in the work-up:

• Establish the presence of true vertigo and differentiate between vertigo of central or peripheral origins 2
• Evaluate the need for urgent investigations and referrals 2
• Use a timing-and-triggers approach to characterize the patient's vestibular symptoms as continuous or episodic 3
• Determine whether symptoms are post-exposure or spontaneous, and whether they are triggered or spontaneous 3

Clinical Assessment

The clinical assessment of vertigo includes:

• Orthostatic blood pressure measurement 4
• A full cardiac and neurologic examination 4
• Assessment for nystagmus 4, 2
• The Dix-Hallpike maneuver 4, 2, 5
• The head-impulse test 4
• The test of skew 4

Diagnostic Tests

The following diagnostic tests may be used to evaluate vertigo:

• Audiological testing 2, 6
• Neuroimaging 2, 6
• The Dix-Hallpike test has a sensitivity of 79% and a specificity of 75% for diagnosing benign paroxysmal positional vertigo (BPPV) 5
• The side-lying test has a sensitivity of 90% and a specificity of 75% for diagnosing BPPV 5

Classification of Vertigo

Vertigo can be classified into different types, including:

• Benign paroxysmal positional vertigo (BPPV) 4, 5
• Meniere disease 4
• Vestibular neuritis 4
• Post-exposure acute vestibular syndrome (AVS) 3
• Spontaneous AVS 3
• Triggered episodic vestibular syndrome (EVS) 3
• Spontaneous EVS 3