What is the appropriate workup for a patient presenting with dizziness?

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Last updated: September 29, 2026 • View editorial policy

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Dizziness Workup

The workup for dizziness should be driven by clinical phenotyping using a timing-and-triggers approach, NOT routine imaging—most patients with isolated dizziness do not require neuroimaging at all. 1

Clinical Phenotyping Framework

The first critical step is categorizing the dizziness pattern, which determines the entire diagnostic pathway:

1. Brief Episodic Vertigo (Triggered by Head Movement)

  • Perform Dix-Hallpike maneuver at bedside to diagnose benign paroxysmal positional vertigo (BPPV) 1, 2
  • No imaging is needed if typical nystagmus pattern is present 1
  • Consider MRI only if atypical features suggest central paroxysmal positional vertigo (CPPV)—such as negative or atypical Dix-Hallpike with persistent symptoms 1, 2

2. Acute Vestibular Syndrome (AVS): Continuous Vertigo with Nausea, Gait Instability, Nystagmus

This is where stroke risk matters most. The approach differs based on neurologic findings:

WITHOUT Associated Neurologic Deficits:

  • Use HINTS examination (Head Impulse, Nystagmus, Test of Skew) if you are specifically trained in its use 2
    • Critical caveat: HINTS is inaccurate when performed by untrained clinicians and should NOT be used without proper training 2
  • Add finger rub test to further exclude stroke 2
  • CT head has <1% diagnostic yield and should not be used 1, 2
  • MRI with DWI has only 4% yield in isolated dizziness but is preferred if imaging is needed 1

WITH Associated Neurologic Deficits:

  • MRI with DWI becomes much more valuable (12% diagnostic yield vs 4% without deficits) 1
  • Use MRI as confirmatory test if HINTS suggests central cause or is equivocal 2
  • Look for focal neurologic signs, subtle ocular motor findings, gait imbalance 3

3. Spontaneous Episodic Vestibular Syndrome (Recurrent Episodes)

With Hearing Loss or Tinnitus:

  • Consider Menière disease clinically 1
  • Imaging generally not required unless atypical features

With Brainstem Neurologic Deficits:

  • Search for symptoms/signs of cerebral ischemia 2
  • Do not use CT 2
  • Use CTA or MRA if concern for vertebrobasilar TIA 2
  • Conventional angiography remains gold standard for vertebrobasilar insufficiency confirmation but CTA has nearly 100% sensitivity for vertebral artery dissection 1

4. Chronic Disequilibrium with Ataxia

Cerebellar Pattern:

  • MRI brain without contrast is appropriate initial imaging 1
  • Add contrast if inflammatory, infectious, or neoplastic cause suspected 1

Sensory/Proprioceptive Pattern:

  • MRI cervical and thoracic spine without contrast to evaluate dorsal columns 1
  • Look for compressive myelopathy, B12/copper deficiency effects, tabes dorsalis 1
  • Add contrast if inflammatory/infectious cause suspected 1

5. Nonspecific Dizziness (No Vertigo, Ataxia, or Neurologic Deficits)

This is the most over-imaged scenario. 1

  • Imaging is usually NOT indicated 1
  • CT diagnostic yield is <1% 1
  • MRI DWI yield is only 4% 1
  • Consider systemic causes: dehydration, hypotension, vasovagal reaction, anxiety, autonomic dysfunction 1
  • All patients with isolated dizziness who had positive CT findings were already suspected to have central cause on bedside evaluation 1

Key Diagnostic Pitfalls

  1. HINTS misuse: Most emergency physicians lack proper training—using HINTS incorrectly is worse than not using it 2. If untrained, rely on presence of neurologic deficits and gait assessment instead.

  2. Over-reliance on CT: CT misses up to 50% of small brainstem strokes early on 3. If stroke is a concern, proceed directly to MRI with DWI.

  3. Imaging isolated dizziness: The trend toward increased imaging (22% getting CT, 10% getting MRI) has not improved outcomes given the extremely low yield 1

  4. Missing vertebrobasilar TIA: In episodic symptoms with brainstem signs, vascular imaging (CTA/MRA) is essential 2

Essential Bedside Examinations

  • Orthostatic vital signs for all patients 4
  • Dix-Hallpike maneuver for triggered symptoms 2, 4
  • HINTS examination only if properly trained and patient has nystagmus 2
  • Gait assessment in patients without nystagmus 2
  • Focused neurologic exam for focal deficits 3, 4

Bottom line: Clinical phenotyping determines imaging need—most dizziness requires no imaging at all, and when imaging is needed, MRI with DWI is superior to CT for detecting dangerous causes. 1, 2

References

1
Guideline

acr appropriateness criteria® dizziness and ataxia: 2023 update.

Journal of the American College of Radiology, 2024

2
Research

Guidelines for reasonable and appropriate care in the emergency department 3 (GRACE-3): Acute dizziness and vertigo in the emergency department.

Academic emergency medicine : official journal of the Society for Academic Emergency Medicine, 2023

4
Research

Dizziness: Evaluation and Management.

American family physician, 2023

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This information is intended for healthcare professionals. Any medical decision-making should rely on clinical judgment and independently verified information. The content provided herein does not replace professional discretion and should be considered supplementary to established clinical guidelines. Healthcare providers should verify all information against primary literature and current practice standards before application in patient care. Dr.Oracle assumes no liability for clinical decisions based on this content.