What is the recommended initial workup for a patient experiencing vertigo when looking up?

Initial Workup for Vertigo When Looking Up

The recommended initial workup for a patient experiencing vertigo when looking up should include the Dix-Hallpike maneuver as the primary diagnostic test, with no routine imaging indicated unless there are neurological red flags or atypical features. 1, 2

Diagnostic Approach

Step 1: Focused History

• Determine timing and triggers of vertigo:
  • Episodic and positional (seconds to minutes) suggests BPPV
  • Prolonged (hours to days) suggests vestibular neuritis or stroke
  • Associated with hearing loss or tinnitus suggests Ménière's disease
• Identify specific triggers:
  • Looking up, rolling over in bed, or bending forward strongly suggests BPPV
  • Spontaneous episodes without positional triggers may suggest other causes

Step 2: Physical Examination

1. Dix-Hallpike maneuver (cornerstone test for posterior canal BPPV):

   • Position patient with head turned 45° to one side, then rapidly move to supine with head hanging 20° below horizontal
   • Observe for characteristic torsional upbeating nystagmus with 5-20 second latency
   • Positive test confirms posterior canal BPPV 1, 2

2. Supine roll test (if Dix-Hallpike negative):

   • Performed to assess for lateral canal BPPV
   • Patient lies supine with head neutral, then quickly rotated 90° to each side
   • Observe for horizontal direction-changing nystagmus 1

3. HINTS examination (for acute vestibular syndrome):

   • Head-Impulse test
   • Nystagmus evaluation
   • Test of Skew
   • Highly sensitive (92.9%) and specific (83.4%) for central causes 2

4. Neurological examination:

   • Cranial nerves, motor strength, coordination, gait
   • Look for red flags suggesting central causes 2

Step 3: Laboratory Testing

• Generally not required in the initial evaluation of positional vertigo
• Consider basic metabolic panel and glucose if systemic symptoms present

Imaging Recommendations

Imaging is NOT routinely recommended for typical BPPV 1, 2

Imaging should be considered only in the following circumstances:

• Abnormal neurological examination
• Direction-changing nystagmus without changes in head position
• Downbeating nystagmus on Dix-Hallpike
• Failure to respond to appropriate repositioning maneuvers
• Associated neurological symptoms or signs
• High vascular risk with acute vestibular syndrome

When imaging is indicated:

• MRI brain without contrast is the preferred modality
• CT head has very low sensitivity (28.5%) for central causes 3
• The diagnostic yield for head CT ordered in the emergency department for acute dizziness is low (2.2%) 1

Management Based on Diagnosis

1. For BPPV (most common cause of positional vertigo):

   • Canalith repositioning procedure (Epley maneuver) for posterior canal BPPV
   • Appropriate roll maneuvers for lateral canal BPPV
   • No medications typically needed

2. For vestibular neuritis:

   • Consider short-term vestibular suppressants (e.g., meclizine 25-100mg daily) 4
   • Vestibular rehabilitation

3. For central causes (if identified):

   • Urgent neurological evaluation
   • Appropriate imaging and management based on etiology

Common Pitfalls to Avoid

1. Overreliance on imaging: MRI will miss approximately 20% of strokes if performed early, and CT has very poor sensitivity (28.5%) 3

2. Overuse of vestibular suppressants: Meclizine and other suppressants can cause drowsiness and delay central compensation 4, 5

3. Failure to perform appropriate positional testing: The Dix-Hallpike and supine roll tests are essential for diagnosis of BPPV

4. Missing red flags for central causes: Neurological symptoms, new-onset headache, or atypical nystagmus patterns require further evaluation

5. Inadequate patient counseling: Patients should be advised about fall risk, especially the elderly 1

By following this systematic approach, clinicians can efficiently diagnose the cause of positional vertigo and implement appropriate management strategies while avoiding unnecessary testing.