What is the diagnostic workup for recurrent dizziness in a 22-year-old male?

From the Guidelines

The diagnostic workup for recurrent dizziness in a 22-year-old male should start with a thorough clinical evaluation, including a detailed history and physical examination, to identify any underlying causes or associated symptoms.

Initial Evaluation

• The HINTS examination (Head Impulse, Nystagmus, Test of Skew) should be performed to distinguish between peripheral and central causes of vertigo 1.
• Bedside tests, such as the Dix-Hallpike maneuver, can help diagnose benign paroxysmal positional vertigo (BPPV) or central paroxysmal positional vertigo (CPPV) 1.

Imaging Evaluation

• Imaging is not always necessary for patients with brief episodic vertigo or isolated dizziness, especially if the HINTS examination is negative or if the patient has a typical presentation of BPPV 1.
• However, imaging may be required to rule out stroke or other central causes of vertigo, especially if the patient has associated neurologic deficits, atypical features, or a lack of response to treatment maneuvers 1.
• MRI is the preferred imaging modality for evaluating vertigo, as it can detect abnormalities in the brainstem, cerebellum, and posterior circulation 1.

Specific Considerations

• Vestibular migraine should be considered in patients with recurrent vertigo, especially if they have associated headache or migrainous features 1.
• Chronic recurrent vertigo with associated brainstem neurologic deficits may suggest vertebrobasilar insufficiency (VBI), which requires further evaluation and management 1. By following this approach, clinicians can efficiently and effectively evaluate and manage patients with recurrent dizziness, while minimizing unnecessary imaging and testing 1.

From the Research

Diagnostic Approach

The diagnostic workup for recurrent dizziness in a 22-year-old male involves a focused approach to differentiate between benign and serious conditions. The following steps can be taken:

• Focus on the timing of the events and triggers of dizziness to develop a differential diagnosis 2
• Categorize patients into three groups based on timing and triggers: acute vestibular syndrome, spontaneous episodic vestibular syndrome, and triggered episodic vestibular syndrome 3, 4
• Use a physical examination to guide the diagnosis, including:
  • Orthostatic blood pressure measurement
  • Full cardiac and neurologic examination
  • Assessment for nystagmus
  • Dix-Hallpike maneuver (for patients with triggered dizziness)
  • HINTS (head-impulse, nystagmus, test of skew) examination when indicated 2, 3, 4

Differential Diagnosis

The differential diagnosis for recurrent dizziness is broad and includes:

• Peripheral etiologies:
  • Benign paroxysmal positional vertigo
  • Meniere disease
  • Vestibular neuritis
  • Labyrinthitis
• Central etiologies:
  • Vestibular migraine
  • Transient ischemic attack
  • Posterior circulation strokes
• Other causes:
  • Orthostatic hypotension
  • Anxiety and psychiatric disorders
  • Medication side effects

Laboratory Testing and Imaging

Laboratory testing and imaging are usually not required but can be helpful in certain cases. The goal is to identify the underlying cause of the dizziness and guide treatment 2, 5, 6.