Vertigo Screening and Testing: Evidence-Based Approach
For vertigo evaluation, use a timing and trigger-based framework rather than symptom quality descriptions, with bedside physical examination techniques (HINTS, Dix-Hallpike) as the primary diagnostic tools—imaging is not routinely indicated. 1, 2
Algorithmic Framework by Clinical Presentation
The modern approach categorizes vertigo into three vestibular syndromes based on timing and triggers 1, 2, 3:
1. Triggered Episodic Vestibular Syndrome (Brief episodes with head movement)
Primary screening test: Dix-Hallpike maneuver 2, 4
- This identifies benign paroxysmal positional vertigo (BPPV), the most common cause
- Do NOT use CT or MRI routinely unless atypical features are present 2
- If Dix-Hallpike is positive for posterior canal BPPV, treat immediately with Epley maneuver 2
- For lateral canal involvement, use supine roll test 3
2. Acute Vestibular Syndrome (Persistent vertigo with nausea, gait instability, nystagmus)
Critical distinction: Peripheral vs. central causes (stroke risk)
For patients WITH nystagmus:
- Use HINTS examination (Head Impulse, Nystagmus, Test of Skew) if the clinician is trained in its use 2
- Add finger rub test to further exclude stroke 2
- Do NOT use brain CT (very low yield at ~2%) 1, 2
- Do NOT use routine MRI as first-line if trained HINTS examiner available 2
- Use MRI as confirmatory test only if HINTS is central or equivocal 2
Critical caveat: As of 2023, HINTS testing is inaccurate when applied by emergency clinicians without specialized training 2. Most emergency physicians have not received this training, so it is not standard of care in routine practice 2.
For patients WITHOUT nystagmus:
- Use severity of gait unsteadiness to distinguish central from peripheral causes 2
3. Spontaneous Episodic Vestibular Syndrome (Recurrent episodes without triggers)
With hearing loss/tinnitus (suspect Menière disease):
- Pure tone audiometry is essential 5
- Bithermal caloric testing 5
- Do NOT use CT 2
- Use CT angiography or MRI angiography only if concern for TIA 2
With brainstem neurologic deficits (suspect vertebrobasilar insufficiency):
Essential Bedside Examination Components
All clinicians evaluating vertigo should be trained in: 2
- HINTS examination (for acute vestibular syndrome with nystagmus)
- Dix-Hallpike test (for positional vertigo)
- Epley maneuver (therapeutic for BPPV)
- Head Impulse Test (HIT) 6
- Dynamic Visual Acuity (DVA) 6
- Gaze nystagmus assessment 6
- Romberg and Unterberger tests 6
This bedside test combination shows 88% sensitivity for vestibular pathology compared to caloric testing 6.
Advanced Vestibular Testing (Specialist Setting)
When bedside examination is inconclusive or for chronic symptoms: 5, 7
- Video head impulse test (vHIT) - quantitative canal function assessment
- Cervical and ocular vestibular evoked myogenic potentials (VEMPs) - otolith function
- Videonystagmography (VNG) with oculomotor tests
- Bithermal caloric testing
These allow comprehensive assessment of all 5 vestibular sensory elements 7.
Imaging Indications
Imaging is NOT routinely recommended 1, 2. The positivity rate of head CT in emergency departments for dizziness/vertigo is only ~2% 1.
Use MRI when:
- HINTS examination suggests central pathology 2
- Associated neurologic symptoms present (increases MRI yield to 12%) 1
- Atypical features in presumed BPPV 2
- Chronic disequilibrium with cerebellar ataxia signs 1
Use vascular imaging (CTA/MRA) when:
Common Pitfalls to Avoid
- Do not rely on patient descriptions of "spinning" vs "lightheadedness" - these are unreliable 1, 4
- Do not perform HINTS if not properly trained - accuracy is poor without specialized training 2
- Do not order CT for vertigo workup - extremely low yield and not recommended 1, 2
- Do not skip the Dix-Hallpike test in positional vertigo - it's diagnostic and therapeutic guidance follows immediately 2