What is the initial approach to a patient presenting with dizziness?

Initial Approach to the Patient with Dizziness

The initial approach to a patient presenting with dizziness should focus on determining the timing and triggers of symptoms rather than the quality of dizziness, as this provides the most reliable diagnostic information. 1, 2, 3

Step 1: Classify the Dizziness Pattern

• Acute Vestibular Syndrome (AVS): Continuous vertigo lasting days, often with nausea/vomiting

  • Requires urgent evaluation to distinguish peripheral causes (vestibular neuritis) from central causes (stroke)
  • HINTS examination (Head-Impulse, Nystagmus, Test of Skew) is critical when performed by trained practitioners 1

• Episodic Triggered Vertigo: Brief episodes triggered by specific head movements

  • Strongly suggests Benign Paroxysmal Positional Vertigo (BPPV)
  • Confirm with Dix-Hallpike maneuver 1

• Spontaneous Episodic Vertigo: Recurrent vertigo without clear positional triggers

  • Consider Meniere's disease (especially with hearing loss), vestibular migraine, TIA

• Chronic Dizziness/Disequilibrium: Persistent unsteadiness

  • Often multifactorial, may represent incomplete compensation from prior vestibular injury 4

Step 2: Focused Physical Examination

• Vital signs and orthostatic measurements: To identify cardiovascular causes

• Neurological examination: Assess for focal deficits suggesting central pathology

• Vestibular examination:

  • Nystagmus assessment: Direction, trigger factors, fatiguability
  • Dix-Hallpike maneuver: For posterior canal BPPV 1
  • Supine roll test: For horizontal canal BPPV 1
  • HINTS examination: For acute vestibular syndrome to distinguish peripheral from central causes 1, 3

• Gait and balance assessment: Evaluate fall risk, especially in elderly patients 1

Step 3: Risk Stratification

• High-risk features requiring urgent evaluation:

  • Acute persistent vertigo with abnormal neurological examination or HINTS examination suggesting central cause
  • Associated neurological symptoms (dysarthria, diplopia, dysphagia, weakness)
  • New-onset severe headache with vertigo
  • Risk factors for stroke (hypertension, diabetes, atrial fibrillation, advanced age) 1

• Moderate-risk features:

  • First episode of severe vertigo without clear BPPV pattern
  • Elderly patients with imbalance and fall risk
  • Symptoms not fitting classic peripheral vestibular patterns

• Lower-risk features:

  • Classic BPPV with positive Dix-Hallpike and no neurological deficits
  • Recurrent episodes with prior similar evaluation
  • Clear association with positional changes and no neurological symptoms

Step 4: Diagnostic Testing

• Imaging:

  • Not routinely indicated for typical BPPV or peripheral vertigo 1
  • MRI brain without contrast is appropriate for:
    • Acute persistent vertigo with abnormal neurological exam or HINTS suggesting central cause
    • Treatment failures not responding to appropriate maneuvers
    • Atypical presentations or neurological symptoms 1

• Laboratory testing:

  • Generally not required for isolated dizziness
  • Consider based on clinical suspicion for specific conditions (anemia, electrolyte disorders)

Step 5: Initial Management

• For BPPV: Canalith repositioning procedures (Epley maneuver) with success rates of 90-98% 1

• For Acute Vestibular Syndrome:

  • If peripheral: Short-term vestibular suppressants, vestibular rehabilitation
  • If central: Urgent neurology consultation and appropriate management

• For chronic dizziness: Vestibular rehabilitation, address underlying causes, avoid long-term vestibular suppressants 4

Special Considerations

• Elderly patients: Higher risk for falls and complications; assess fall risk and home safety 1

• Treatment failures: Reevaluate for:

  1. Persistent or converted BPPV (different canal involvement)
  2. Coexisting vestibular disorders
  3. Central nervous system disorders masquerading as peripheral vertigo 1

• Common pitfalls:

  • Over-reliance on patient's description of dizziness quality
  • Failure to perform appropriate positional testing
  • Premature imaging without appropriate clinical assessment
  • Prolonged use of vestibular suppressants impeding central compensation
  • Missing central causes of vertigo (especially posterior circulation strokes)

By following this structured approach, clinicians can efficiently diagnose and manage patients with dizziness while appropriately identifying those who require urgent evaluation for potentially serious central causes.