From the Guidelines
The workup for vertigo should begin with a thorough history and physical examination, including the Dix-Hallpike maneuver and head impulse test, to distinguish between peripheral and central causes, as recommended by the American Academy of Otolaryngology-Head and Neck Surgery 1. The initial evaluation should focus on identifying red flags for central causes of vertigo, such as stroke, multiple sclerosis, or tumors, which may require urgent imaging studies like MRI or CT.
- Key elements of the history include onset, duration, triggers, and associated symptoms like hearing loss or neurological symptoms.
- The physical examination should include tests like the Dix-Hallpike maneuver for benign paroxysmal positional vertigo (BPPV) and the head impulse test to assess vestibular function.
- Basic laboratory tests, such as complete blood count, metabolic panel, thyroid function, and vitamin B12 levels, should be performed to rule out metabolic causes.
- Audiometry is recommended for patients with hearing symptoms to evaluate for Meniere's disease or acoustic neuroma.
- Vestibular function tests like electronystagmography or videonystagmography may help assess the vestibular system.
- Imaging studies are indicated when central causes are suspected, with MRI of the brain being the preferred modality to evaluate for stroke, multiple sclerosis, or tumors, while CT may be used in emergency situations, as suggested by the American College of Radiology 1.
- For persistent unexplained vertigo, referral to specialists like otolaryngologists, neurologists, or vestibular therapists is appropriate, as they can provide further evaluation and management, including repositioning maneuvers for BPPV or vestibular rehabilitation for other conditions, as recommended by the American Academy of Otolaryngology-Head and Neck Surgery 1.
From the Research
Workup for Vertigo
The workup for vertigo involves a thorough history and physical examination to determine whether the patient has a peripheral or central cause of vertigo 2, 3, 4.
- History: The timing and duration of symptoms, provoking factors, and associated signs and symptoms are important clues to the diagnosis 2, 4.
- Physical Examination: A careful examination of the head and neck and neurologic systems, as well as special tests such as the Dix-Hallpike maneuver, can help distinguish between peripheral and central causes of vertigo 2, 4, 5.
- Peripheral vs. Central Causes: Peripheral causes of vertigo, such as benign paroxysmal positional vertigo (BPPV), vestibular neuronitis, and Meniere's disease, are usually benign and can be treated with reassurance and management of symptoms 3, 5. Central causes of vertigo, such as cerebrovascular disease, migraine, and intracranial neoplasms, often require urgent treatment and further work-up with selected laboratory and radiologic studies such as magnetic resonance imaging (MRI) 2, 6.
Diagnostic Tests
- Dix-Hallpike Maneuver: A test used to diagnose BPPV 2, 4, 5.
- Head-Impulse Test: A test used to assess vestibular function 4, 5.
- Audiological Testing: May be useful in evaluating patients with vertigo, particularly those with suspected Meniere's disease 4.
- Neuroimaging: May be necessary to rule out central causes of vertigo, such as stroke or intracranial neoplasms 2, 6.
Treatment
- Benign Paroxysmal Positional Vertigo (BPPV): Can be treated with a canalith repositioning procedure, such as the Epley maneuver 5.
- Meniere's Disease: Treatment includes salt restriction and diuretics 5.
- Vestibular Neuronitis: Symptoms can be relieved with vestibular suppressant medications and vestibular rehabilitation 5.