Do I need to consult neurology for a patient being worked up for dizziness?

Neurology Consultation for Dizziness Workup

Neurology consultation is not routinely necessary for most patients with dizziness but should be obtained when specific red flags are present, including abnormal HINTS examination, neurological deficits, high vascular risk, or symptoms not responding to initial management. 1

Initial Diagnostic Approach

The diagnostic approach to dizziness should focus on timing and triggers rather than symptom quality:

1. Determine the pattern and triggers of dizziness:

   • Brief episodes triggered by position changes suggest BPPV (most common in elderly)
   • Sustained episodes with neurological symptoms warrant further investigation
   • Isolated vertigo episodes may precede stroke by weeks/months in vertebrobasilar insufficiency 1

2. Perform targeted physical examination:

   • Dix-Hallpike test for BPPV
   • HINTS examination (Head-Impulse, Nystagmus, Test of Skew) to differentiate peripheral vs. central causes
   • Complete neurological assessment including cranial nerves
   • Orthostatic blood pressure measurements 1

When to Consult Neurology

Neurology consultation is indicated in the following scenarios:

• Abnormal HINTS examination suggesting central etiology
• Presence of neurological deficits accompanying dizziness
• High vascular risk patients with acute vestibular syndrome even with normal examination
• Chronic undiagnosed dizziness not responding to initial treatment
• Vertigo with occipital headache (possible vertebrobasilar insufficiency)
• Symptoms suggestive of stroke or TIA 1, 2

Research shows that neurological consultation has a substantial diagnostic yield (21%) when used appropriately for dizzy patients 2.

When Neuroimaging is Indicated

Brain MRI (without contrast) is recommended for:

• Acute vestibular syndrome with abnormal HINTS examination
• Dizziness with neurological deficits
• High vascular risk patients with acute vestibular syndrome
• Chronic undiagnosed dizziness not responding to treatment 1

Management Algorithm

1. For positional vertigo lasting seconds (likely BPPV):

   • Perform Dix-Hallpike test
   • If positive, perform appropriate canalith repositioning procedure (e.g., Epley maneuver)
   • Neurology consultation not typically needed 1

2. For acute prolonged vertigo without neurological symptoms:

   • Perform HINTS examination
   • If normal HINTS and no risk factors, treat symptomatically
   • If abnormal HINTS or neurological symptoms present, obtain neuroimaging and neurology consultation 1, 3

3. For recurrent episodes with headache/migraine features:

   • Consider vestibular migraine
   • Neurology consultation may be beneficial for management 1, 4

4. For chronic dizziness:

   • Evaluate for multifactorial causes (vestibular, cardiovascular, neurological)
   • If not responding to initial management or if neurological symptoms develop, obtain neurology consultation 1, 4

Common Pitfalls to Avoid

• Overreliance on symptom quality rather than timing and triggers for diagnosis
• Failure to perform HINTS examination in acute vestibular syndrome, which can miss central causes
• Routine neuroimaging without clinical indications (low yield)
• Prolonged use of vestibular suppressants, which can impede central compensation 1, 4

Remember that while neurological consultation has value in selected cases (with 21% diagnostic yield for serious neurological disease), it is not necessary for all dizzy patients 2. The diagnostic approach should be systematic and focused on identifying those patients who truly need specialist evaluation.