How should I evaluate and manage a patient presenting with vertigo (spinning sensation)?

Approach to a Patient with Giddiness/Spinning Sensation (Vertigo)

Begin by categorizing the patient into one of four temporal patterns through focused history-taking: triggered/positional episodes, spontaneous brief episodes, acute continuous vertigo, or chronic imbalance—this classification immediately narrows your differential and directs bedside testing.

Initial History: Timing and Triggers

The most critical first step is determining the temporal pattern of symptoms 1:

• Triggered (positional) episodes: Vertigo provoked by specific head movements (rolling in bed, looking up, bending forward) lasting <1 minute → suspect BPPV
• Spontaneous episodic: Recurrent attacks without positional triggers, lasting minutes to hours → consider vestibular migraine, Ménière's disease, or TIA
• Acute vestibular syndrome (AVS): Continuous vertigo lasting >24 hours with nausea/vomiting → differentiate peripheral (vestibular neuritis) from central (stroke)
• Chronic imbalance: Persistent disequilibrium → consider cerebellar or sensory ataxia

Ask specifically: "Does the room spin when you roll over in bed or look up?" versus "Did the spinning start suddenly and hasn't stopped?" This single distinction changes your entire diagnostic pathway 2.

Physical Examination: What to Actually Look For

For Triggered/Positional Vertigo (Suspected BPPV)

Perform the Dix-Hallpike maneuver immediately 1, 3:

• Turn patient's head 45° to one side while seated
• Rapidly move patient to supine position with head extended 20° off table edge
• Positive test: Torsional upbeating nystagmus with 5-20 second latency, lasting <60 seconds, accompanied by vertigo
• Repeat on opposite side if first side negative
• If horizontal nystagmus appears instead, perform supine roll test for lateral canal BPPV 1

For Acute Continuous Vertigo (AVS)

If trained in HINTS examination (Head Impulse, Nystagmus, Test of Skew), apply it ONLY in patients with ongoing nystagmus 2:

• Central features suggesting stroke: downbeating nystagmus, direction-changing nystagmus without head position change, negative head impulse test, skew deviation 3
• Peripheral features: unidirectional horizontal-torsional nystagmus, positive head impulse test, no skew deviation

Critical caveat: HINTS is inaccurate when performed by untrained clinicians and should NOT be used in patients without nystagmus 2. If you lack HINTS training, assess gait stability and look for focal neurologic signs instead.

Red Flags Requiring Immediate Neuroimaging

Look for these central nervous system warning signs 3, 4:

• Dysarthria, dysphagia, dysmetria
• Facial numbness or weakness
• Limb weakness or sensory loss
• Severe gait instability (cannot walk independently)
• New severe headache
• Horner's syndrome
• Vertical or direction-changing nystagmus

Diagnostic Testing: When and What to Order

What NOT to Order

Do not obtain CT brain for isolated vertigo meeting BPPV criteria or typical peripheral vestibular patterns 1, 2. CT has only ~2% positivity rate in undifferentiated vertigo and misses posterior fossa strokes.

Do not order vestibular testing (VNG, rotary chair) acutely unless diagnosis remains unclear after bedside examination 1.

When to Image

Order MRI with diffusion-weighted imaging if 1, 2:

• Central features on examination (red flags above)
• HINTS examination is central or equivocal (if you're trained)
• Persistent symptoms despite appropriate treatment
• Age >60 with vascular risk factors and spontaneous episodic vertigo (consider TIA)

Important limitation: Early MRI may be false-negative in 20-50% of small brainstem strokes within first 24-48 hours 5, 6.

Management Based on Diagnosis

Posterior Canal BPPV (Most Common)

Treat immediately with canalith repositioning procedure (Epley maneuver) 1, 3:

• Strong recommendation with high-quality evidence
• Do NOT recommend post-procedural positioning restrictions (no benefit demonstrated) 1
• Reassess within 1 month 1
• Vestibular rehabilitation is an option if Epley fails 1

Vestibular Neuritis

Consider short-term corticosteroids (within 72 hours of onset) 2. Do NOT routinely use vestibular suppressants (antihistamines, benzodiazepines) beyond acute symptom control 1, 3.

Vestibular Migraine

Distinguish from BPPV by: episodes lasting 5 minutes to 72 hours, migraine history, photophobia/phonophobia during attacks, no sustained response to repositioning maneuvers 3.

Risk Stratification: Modifying Factors

Assess fall risk immediately, especially in elderly patients 3, 1:

• 12-fold increased fall risk in symptomatic older adults
• 9% of geriatric patients have undiagnosed BPPV
• Document: impaired mobility, CNS disorders, lack of home support, prior falls
• Counsel on home safety and activity restrictions until resolved 3

Follow-Up and Safety Net

Reassess within 1 month to document symptom resolution 1. If symptoms persist, re-evaluate for:

• Unresolved BPPV (wrong canal diagnosed, incomplete treatment)
• Alternative peripheral vestibular disorder
• Central nervous system pathology 1

Educate patients about BPPV recurrence (common), fall risk, and when to return: new neurologic symptoms, hearing loss, continuous vertigo >24 hours, or failure to improve with treatment 1, 3.

Common Pitfalls to Avoid

1. Ordering CT brain reflexively: Wastes resources, exposes to radiation, misses strokes
2. Using HINTS without proper training: Leads to misdiagnosis and missed strokes 2
3. Applying HINTS to patients without nystagmus: Not validated, will mislead you 2
4. Prescribing vestibular suppressants for BPPV: Delays recovery, increases fall risk 1, 3
5. Missing BPPV entirely: The dominant diagnostic error in vertigo care is failing to perform positional testing 6