From the Guidelines
The diagnostic workup for persistent vertigo (dizziness) should start with a thorough clinical evaluation, including a neurologic examination and bedside tests such as the HINTS examination to distinguish between peripheral and central causes of vertigo 1.
Key Components of the Diagnostic Workup
- History and physical examination: to identify associated symptoms and signs, such as nausea, vomiting, gait instability, nystagmus, and head-motion intolerance 1
- HINTS examination: a bedside test that can help distinguish between peripheral and central causes of vertigo, with a high sensitivity and specificity when performed by specially trained practitioners 1
- Imaging studies: may be necessary to rule out central causes of vertigo, such as stroke or multiple sclerosis, especially in patients with abnormal neurologic examination or HINTS examination 1
Imaging Studies
- CT or MRI: may be used to evaluate patients with persistent vertigo, especially those with abnormal neurologic examination or HINTS examination, to rule out central causes such as stroke or multiple sclerosis 1
- Diffusion-weighted imaging (DWI) MRI: may be used to evaluate patients with acute vestibular syndrome (AVS) to rule out stroke, with a higher diagnostic yield than CT 1
Special Considerations
- Vestibular migraine: may mimic persistent vertigo, but often has associated headache and other migrainous features, and does not require imaging to diagnose 1
- Benign paroxysmal positional vertigo (BPPV): may be diagnosed clinically, and imaging is not necessary unless there are atypical features or lack of response to treatment maneuvers 1
From the Research
Diagnostic Approach
The diagnostic workup for persistent vertigo (dizziness) involves a systematic approach to identify the underlying cause. According to 2, a systematic diagnostic workup is essential to determine the cause of chronic dizziness. The patient history can classify dizziness into one of four categories: vertigo, disequilibrium, presyncope, or lightheadedness 3.
Classification of Dizziness
The classification of dizziness can be based on the timing and triggers, which includes:
- Acute vestibular syndrome
- Spontaneous episodic vestibular syndrome
- Triggered episodic vestibular syndrome 4 This approach can help differentiate benign peripheral vestibular conditions from dangerous posterior circulation strokes.
Diagnostic Tests
The diagnostic workup may include physical examination tests, such as:
- Evaluation for nystagmus
- The Dix-Hallpike maneuver
- Orthostatic blood pressure testing 3 Laboratory testing and radiography play a limited role in diagnosis, and a final diagnosis is not obtained in about 20% of cases 3.
Treatment
Treatment of vertigo includes:
- The Epley maneuver (canalith repositioning) and vestibular rehabilitation for benign paroxysmal positional vertigo
- Intratympanic dexamethasone or gentamicin for Meniere disease
- Steroids for vestibular neuritis 3 Vestibular rehabilitation is also effective in treating chronic vestibular syndrome 2.
Key Points
- A systematic diagnostic workup is essential to determine the cause of chronic dizziness
- The classification of dizziness can be based on the timing and triggers
- Physical examination tests, such as the Dix-Hallpike maneuver, can help diagnose the underlying cause
- Treatment of vertigo depends on the underlying cause, and vestibular rehabilitation is often effective 2, 3, 4, 5, 6