What tests and evaluations are used to diagnose and manage vertigo?

Diagnostic Testing for Vertigo

The diagnosis of vertigo requires a systematic approach including specific bedside tests, targeted history-taking, and selective use of imaging and laboratory studies based on clinical presentation.

Initial Evaluation

• History assessment should focus on:

  • Timing and duration of symptoms
  • Provoking factors and triggers
  • Associated symptoms (hearing loss, tinnitus, ear fullness)
  • Presence of neurological symptoms 1

• Physical examination must include:

  • Detailed neurological examination
  • Orthostatic blood pressure measurement (drop ≥20 mmHg systolic or ≥10 mmHg diastolic indicates orthostatic hypotension) 1
  • 12-lead ECG to rule out cardiac causes 1

Key Diagnostic Tests

Bedside Tests

1. Dix-Hallpike Maneuver - Gold standard for diagnosing posterior canal BPPV

   • Patient brought from upright to supine position with head turned 45° to one side and neck extended 20° 2
   • Positive test: vertigo with torsional, upbeating nystagmus 2

2. Supine Roll Test

   • Performed when Dix-Hallpike is negative but BPPV is suspected
   • Assesses for lateral semicircular canal BPPV 2

3. HINTS Examination (Head-Impulse, Nystagmus, Test of Skew)

   • Critical for differentiating peripheral from central vertigo
   • Abnormal HINTS exam suggests central pathology requiring urgent evaluation 1, 3

Laboratory Testing

• Basic laboratory tests:

  • Complete blood count
  • Basic metabolic panel
  • Blood glucose
  • Thyroid function tests 1

• Audiometric Testing

  • Essential for evaluating hearing loss associated with vertigo
  • Particularly important in suspected Ménière's disease 2

Vestibular Testing

• Video- or Electronystagmography (VNG/ENG)

  • Evaluates vestibular function, brain vestibular centers, and oculomotor system
  • Indicated when diagnosis is unclear or presentation is atypical 2, 1

• Electrocochleography

  • Measures electrical responses of cochlea and auditory nerve
  • Helpful in diagnosing Ménière's disease 2

Imaging Studies

• MRI Brain

  • Preferred imaging modality for persistent vertigo with neurological symptoms (central vertigo)
  • Should be performed without IV contrast, or without and with IV contrast 2, 1
  • Indicated for:
    • Acute Vestibular Syndrome with abnormal HINTS exam
    • Presence of neurological deficits
    • High vascular risk patients even with normal examination
    • Chronic undiagnosed dizziness not responding to treatment 1

• CT Temporal Bone

  • Without IV contrast for peripheral vertigo evaluation
  • Useful for assessing bony abnormalities of the temporal bone 2

• MRA Head and Neck

  • Used to detect vascular stenosis or occlusion
  • Indicated when vertebrobasilar insufficiency is suspected 2

Risk Stratification

• Sudbury Vertigo Risk Score

  • Score >8 requires urgent neuroimaging and neurological consultation due to 41% risk of serious underlying pathology 1

• Red flags requiring immediate evaluation:

  • Sudden severe headache with dizziness
  • New neurological symptoms
  • Inability to walk or stand
  • Persistent vomiting with dizziness
  • Altered mental status 1

Follow-up and Monitoring

• Reassessment within 1 month after initial treatment to document resolution or persistence of symptoms 2, 1

• Validated assessment tools to track progress:

  • Activities-Specific Balance Confidence Scale
  • Dizziness Handicap Inventory
  • Dynamic Gait Index
  • Timed Up & Go test 1

Common Pitfalls to Avoid

1. Relying solely on symptom quality rather than timing and triggers for diagnosis 3

2. Overuse of imaging in patients who meet diagnostic criteria for BPPV without additional signs/symptoms 2

3. Routine use of vestibular suppressant medications which can interfere with central compensation 2, 1

4. Failure to recognize central causes of vertigo, which require urgent treatment (watch for downbeating nystagmus, direction-changing nystagmus, persistent nystagmus, and severe imbalance) 1

5. Missing stroke as a cause of vertigo - accounts for 3-7% of all vertigo cases and requires immediate intervention 4

By following this diagnostic approach, clinicians can effectively differentiate between peripheral and central causes of vertigo, leading to appropriate management strategies and improved patient outcomes.