What is the initial workup for a 51-year-old male presenting with dizziness?

Initial Workup for Dizziness in a 51-Year-Old Male

The initial workup for a 51-year-old male presenting with dizziness should focus on categorizing the type of dizziness and performing targeted physical examination tests, with the Dix-Hallpike maneuver being the cornerstone diagnostic test for the most common cause, benign paroxysmal positional vertigo (BPPV). 1

Step 1: Targeted History

Focus on timing and triggers rather than the quality of symptoms:

• Timing patterns:

  • Episodic vs. continuous
  • Duration of episodes (seconds, minutes, hours, days)
  • Onset (sudden vs. gradual)

• Triggers:

  • Head position changes (suggests BPPV)
  • Standing up (suggests orthostatic hypotension)
  • Specific movements or activities
  • No clear trigger (may suggest vestibular neuritis)

• Associated symptoms:

  • Hearing loss or tinnitus (suggests Meniere's disease)
  • Neurological symptoms (headache, diplopia, dysarthria, numbness)
  • Nausea/vomiting
  • Fall risk or history of falls

Step 2: Physical Examination

1. Vital signs with orthostatic blood pressure measurements

2. Vestibular examination:

   • Dix-Hallpike maneuver - essential for diagnosing posterior canal BPPV 2

     • Position patient 45° to one side with neck extended 20°
     • Look for characteristic nystagmus with 5-20 second latency
     • Nystagmus should resolve within 60 seconds
     • Repeat on opposite side if negative

   • Supine Roll Test - for lateral canal BPPV if Dix-Hallpike is negative 2

   • HINTS examination - if acute vestibular syndrome present 1

     • Head Impulse test
     • Nystagmus evaluation
     • Test of Skew

3. Complete neurological examination

   • Cranial nerves
   • Motor strength
   • Coordination (finger-to-nose, heel-to-shin)
   • Gait assessment

4. Cardiovascular examination

Step 3: Red Flags Requiring Further Evaluation

• Direction-changing nystagmus without head position changes
• Downbeating nystagmus on Dix-Hallpike
• Baseline nystagmus without provocative maneuvers
• Associated neurological deficits
• Failure to respond to appropriate repositioning maneuvers
• New-onset dizziness in a patient with vascular risk factors 1

Step 4: Diagnostic Testing

• Laboratory testing: Generally not required initially unless specific concerns 3, 4

  • Consider CBC, electrolytes, glucose if clinically indicated

• Imaging: Not routinely recommended for typical BPPV 2, 1

  • MRI brain without contrast indicated if:
    • Abnormal HINTS examination
    • Neurological deficits present
    • High vascular risk with acute vestibular syndrome
    • Chronic undiagnosed dizziness not responding to treatment

Management Based on Diagnosis

• If BPPV confirmed: Perform canalith repositioning procedure (Epley maneuver) 2

• If vestibular neuritis suspected: Consider vestibular suppressants and vestibular rehabilitation 3, 5

• If Meniere's disease suspected: Consider salt restriction and diuretics 3, 4

• If central cause suspected: Urgent neurological evaluation and imaging 1

Important Caveats

• The traditional approach of categorizing dizziness into vertigo, presyncope, disequilibrium, and lightheadedness has limited clinical usefulness 3

• Up to 20% of dizziness cases may remain without a definitive diagnosis despite thorough evaluation 4

• Even seemingly benign dizziness can occasionally mask serious central pathology, as demonstrated in rare cases of brainstem arteriovenous malformations presenting with isolated dizziness 6

• Fall risk assessment and prevention strategies are essential, particularly in older patients 1

In-text citations: 2, 1, 3, 4, 5, 7, 6