How to evaluate and manage a patient with dizziness?

Diagnostic Approach to Dizziness

The most effective approach to evaluating dizziness is to categorize symptoms based on timing and triggers rather than relying on subjective quality descriptions, as this provides a more accurate framework for diagnosis and management. 1

Initial Classification of Dizziness

Dizziness should be categorized into one of four timing/trigger-based syndromes:

1. Acute Vestibular Syndrome (AVS)

   • Continuous dizziness lasting days to weeks
   • Associated with nausea, vomiting, head motion intolerance
   • Common causes: Vestibular neuritis, labyrinthitis, posterior circulation stroke 1

2. Triggered Episodic Vestibular Syndrome

   • Brief episodes triggered by specific actions
   • Typically lasting <1 minute
   • Common cause: Benign Paroxysmal Positional Vertigo (BPPV) 1

3. Spontaneous Episodic Vestibular Syndrome

   • Episodes not triggered by specific actions
   • Lasting minutes to hours
   • Common causes: Vestibular migraine, Ménière's disease, TIA 1

4. Chronic Vestibular Syndrome

   • Dizziness lasting weeks to months
   • Common causes: Anxiety, medication side effects, posterior fossa masses 1

Key Diagnostic Maneuvers

For Triggered Episodic Vestibular Syndrome (suspected BPPV):

• Dix-Hallpike maneuver for posterior canal BPPV

  • Look for delayed onset of vertigo and nystagmus after position change
  • Upbeating and torsional nystagmus lasting <60 seconds
  • Symptoms that fatigue with repeated testing 2

• Supine roll test if Dix-Hallpike is negative but history suggests BPPV

  • Observe for geotropic or apogeotropic nystagmus 1

For Acute Vestibular Syndrome:

• HINTS examination to distinguish peripheral from central causes
  • Head-Impulse: Abnormal in peripheral causes, normal in central causes
  • Nystagmus: Unidirectional in peripheral causes, direction-changing in central causes
  • Test of Skew: Negative in peripheral causes, positive in central causes
  • Sensitivity 92.9%, specificity 83.4% for central causes 1
  • HINTS+ (adding hearing assessment) increases sensitivity to 99% 1

Imaging Recommendations

• MRI head without IV contrast is indicated for:

  • AVS with abnormal HINTS exam
  • AVS with neurological deficits
  • High vascular risk patients with AVS even with normal exam 2, 1

• CT head without IV contrast may be considered when MRI is not immediately available for high-risk patients

  • Low yield (<1%) in isolated dizziness without neurological deficits 2, 1

• No imaging is typically needed for:

  • Typical BPPV with positive Dix-Hallpike test 2, 1

Management Approach

For BPPV:

• Canalith Repositioning Procedures (CRP)
  • Epley maneuver for posterior canal BPPV
  • Modified Epley or Gufoni maneuver for lateral canal BPPV 2, 1

For Vestibular Neuritis/Labyrinthitis:

• Vestibular rehabilitation
• Short-term vestibular suppressants if needed

For Ménière's Disease:

• Low-salt diet
• Diuretics
• Vestibular suppressants during acute attacks 2

For Vestibular Migraine:

• Migraine prophylaxis
• Trigger avoidance

Important Clinical Considerations

• Posterior circulation stroke can present with isolated dizziness in up to 25% of cases (75% in high vascular risk patients) 2, 1

• Recurrence rate of BPPV is approximately 15% per year, up to 50% at 5 years 2, 1

• For persistent symptoms:

  • Reevaluate for correct diagnosis
  • Consider CNS disorders that can masquerade as BPPV (3% of treatment failures)
  • Consider vestibular rehabilitation 1

• Patient education about fall risk is essential, particularly in elderly patients with BPPV 2

• Loss of consciousness is never a symptom of Ménière's disease 2

By systematically applying this approach to dizziness evaluation, clinicians can more effectively distinguish between benign peripheral causes and potentially life-threatening central causes, ensuring appropriate management and disposition.