What diagnostic workup should be performed for a 32‑year‑old woman with recent pregnancy loss who is planning pregnancy and presents with vertigo and possible cervical‑related dizziness?

Diagnostic Workup for Vertigo with Possible Cervical Component

Begin with the Dix-Hallpike maneuver to diagnose or exclude benign paroxysmal positional vertigo (BPPV), as this is the most common cause of episodic vertigo and requires no imaging if typical findings are present 1.

Initial Clinical Assessment

Critical Bedside Testing

Perform the Dix-Hallpike maneuver immediately:

• Positive test shows torsional upbeating nystagmus with 5-20 second latency, lasting <60 seconds
• If positive with typical features: no imaging is needed 2, 1
• If negative or atypical findings (downbeating nystagmus, no latency, persistent nystagmus >60 seconds): proceed to neuroimaging to exclude central causes 2, 1

Red Flags Requiring Immediate Neuroimaging

Look for these specific findings that suggest central nervous system pathology rather than peripheral vertigo 1:

• Downbeating nystagmus on Dix-Hallpike (especially without torsional component)
• Direction-changing nystagmus without head position changes
• Gaze-evoked nystagmus (beats right with right gaze, left with left gaze)
• Baseline nystagmus without provocative maneuvers
• Associated neurologic signs: dysarthria, dysmetria, dysphagia, sensory/motor deficits, Horner's syndrome
• Severe headache with migrainous features (photophobia, phonophobia, visual aura)
• Failure to respond to canalith repositioning procedures

Imaging Decision Algorithm

When Imaging is NOT Needed

• Typical BPPV with positive Dix-Hallpike showing characteristic nystagmus
• Symptoms resolve with Epley maneuver
• No neurologic red flags present

When MRI Brain is Required

Order MRI brain without and with contrast if 2:

• Atypical or negative Dix-Hallpike with persistent positional symptoms (11% detection rate for acute lesions vs 6% for CT)
• Any central nervous system red flags listed above
• Unresponsive to treatment maneuvers
• Short-term symptom recurrence despite appropriate treatment
• Young patient with post-traumatic onset
• Elderly patient with new-onset vertigo

CT head without contrast is inferior to MRI for detecting central causes (6% vs 11% detection rate) and should only be used if MRI is contraindicated or unavailable 2.

Cervicogenic Dizziness Considerations

Cervicogenic dizziness (CGD) is a diagnosis of exclusion that requires ruling out vestibular, vascular, and central causes first 3. For your 32-year-old patient:

Specific CGD Evaluation Steps

1. First exclude BPPV with Dix-Hallpike
2. Assess for vertebral artery dissection risk - particularly important in young women with recent pregnancy (hormonal changes affect vessel walls) 2
3. Evaluate neck pain-dizziness relationship: CGD presents with dizziness associated with neck pain/movement
4. Rule out vestibular migraine: requires ≥5 episodes lasting 5 minutes-72 hours with migrainous features in ≥50% of episodes 1

Vascular Imaging for Cervical Concerns

If cervical vascular pathology is suspected (neck pain, recent trauma, young age with vascular risk factors):

• CTA neck approaches 100% sensitivity for vertebral artery dissection 2
• Consider transcranial Doppler ultrasound as non-invasive alternative for vertebrobasilar insufficiency screening 2

Pregnancy-Specific Considerations

Given recent pregnancy loss and pregnancy planning 4, 5, 6:

• Hormonal changes during pregnancy commonly exacerbate BPPV, Meniere's disease, and vestibular migraine
• Avoid radiation exposure (CT) if possible; prefer MRI if imaging needed
• BPPV treatment (Epley maneuver) is safe and effective during pregnancy
• Document baseline vestibular function before conception if CGD suspected

Common Pitfalls to Avoid

1. Do not order imaging for typical BPPV - this wastes resources and delays appropriate treatment 2, 1
2. Do not miss central causes - 10% of cerebellar strokes present like peripheral vertigo 1
3. Do not diagnose CGD without excluding vestibular and central causes first 3
4. Do not rely on CT when MRI is available - CT misses 45% of acute central lesions detected by MRI 2

Recommended Workup Sequence

1. Dix-Hallpike maneuver (bedside, immediate)
2. If positive with typical features → Epley maneuver (no imaging)
3. If negative/atypical OR red flags present → MRI brain without and with contrast
4. If cervical vascular concern → CTA neck or transcranial Doppler
5. Only after excluding above → consider CGD diagnosis with cervical spine evaluation 3