What is the initial workup for a patient presenting with dizziness?

Initial Workup for Dizziness

The initial workup for a patient presenting with dizziness should focus on determining the timing and triggers of symptoms, followed by targeted physical examination to distinguish between peripheral and central causes, with imaging reserved only for specific concerning features.

Step 1: History Taking - Focus on Timing and Triggers

Rather than relying solely on symptom quality descriptions (vertigo, presyncope, disequilibrium), focus on:

• Timing of symptoms:

  • Brief episodic (seconds to minutes)
  • Prolonged episodic (hours to days)
  • Acute persistent (continuous for days)
  • Chronic (continuous for weeks/months)

• Triggers:

  • Positional changes (head movements)
  • Specific situations (standing, exertion)
  • Spontaneous (no clear trigger)

• Associated symptoms:

  • Hearing loss or tinnitus
  • Neurological symptoms (diplopia, dysarthria, numbness)
  • Headache or migraine history
  • Cardiovascular symptoms (chest pain, palpitations)

Step 2: Physical Examination

• Vital signs including orthostatic blood pressure measurements

• Vestibular/neurological assessment:

  • Dix-Hallpike maneuver to diagnose posterior canal BPPV 1
  • Supine roll test if Dix-Hallpike is negative but BPPV still suspected 1
  • HINTS examination (Head-Impulse, Nystagmus, Test of Skew) for acute persistent vertigo to differentiate peripheral from central causes 1
  • Cranial nerve examination
  • Cerebellar testing (finger-to-nose, heel-to-shin)

• Cardiovascular examination:

  • Heart rate and rhythm
  • Carotid auscultation

Step 3: Initial Testing

• ECG for all patients with dizziness to rule out arrhythmias 1

• Audiometry if hearing loss or tinnitus is present

• Laboratory testing only if specific concerns:

  • CBC if anemia suspected
  • Electrolytes if dehydration or medication effect suspected
  • Glucose if diabetic

Step 4: Imaging (Limited Use)

• MRI brain without contrast is indicated ONLY if:

  • Abnormal neurological examination
  • HINTS examination suggests central cause
  • New-onset severe headache
  • Risk factors for stroke with acute persistent vertigo 1

• CT head without contrast is less sensitive but may be appropriate as initial imaging when MRI is not immediately available and stroke is suspected 1

• Do NOT obtain radiographic imaging in patients who meet diagnostic criteria for BPPV without additional concerning symptoms 1

Common Diagnostic Categories

1. Brief Episodic Vertigo with Positional Trigger

• Most likely BPPV
• Diagnosis: Positive Dix-Hallpike test
• Treatment: Canalith repositioning procedure (e.g., Epley maneuver)

2. Acute Persistent Vertigo

• Differential: Vestibular neuritis vs. posterior circulation stroke
• Key distinction: HINTS examination (normal head impulse test, direction-changing nystagmus, or skew deviation suggests central cause)

3. Recurrent Spontaneous Vertigo with Auditory Symptoms

• Consider Meniere's disease
• Characteristic: Episodic vertigo lasting hours with fluctuating hearing loss, tinnitus, aural fullness

4. Dizziness with Cardiovascular Symptoms

• Consider syncope, orthostatic hypotension, arrhythmia
• Key test: Orthostatic vital signs, ECG

Important Pitfalls to Avoid

• Don't rely solely on symptom quality descriptions (vertigo vs. lightheadedness) as these are often unreliable and don't distinguish benign from serious causes 1, 2

• Don't automatically order neuroimaging for all dizzy patients - diagnostic yield is low (approximately 3-4%) in patients with isolated dizziness without neurological signs 1

• Don't miss posterior circulation strokes - up to 25% of patients with acute vestibular syndrome may have a stroke, and many lack obvious neurological symptoms 1

• Don't forget to perform the Dix-Hallpike maneuver - BPPV is common and easily treatable but frequently missed 1

• Don't overuse vestibular suppressant medications - they can delay central compensation and should not be routinely prescribed for BPPV 1

By following this systematic approach focused on timing and triggers rather than symptom quality alone, clinicians can more accurately diagnose the cause of dizziness, reduce unnecessary testing, and provide appropriate treatment to improve patient outcomes.