Initial Workup and Treatment Approach for Vertigo
The initial workup for vertigo should focus on classifying the pattern based on timing and triggers, performing targeted physical examinations including HINTS testing, and using appropriate imaging only when central causes are suspected. 1
Classification and Initial Assessment
Vertigo should be classified into three main patterns:
- Acute Vestibular Syndrome (AVS) - Sudden onset, continuous vertigo lasting days
- Episodic Vestibular Syndrome - Recurrent episodes of vertigo
- Chronic Vestibular Syndrome - Persistent dizziness lasting months 1
Key Elements of History
- Timing and duration of symptoms
- Specific triggers (position changes, loud sounds)
- Associated symptoms (hearing loss, tinnitus, neurological symptoms)
- Medication review 1, 2
Essential Physical Examination Components
- HINTS examination (Head-Impulse, Nystagmus, Test of Skew) - More sensitive than CT for posterior circulation stroke 1
- Dix-Hallpike maneuver for BPPV
- Complete neurological examination
- Otoscopic examination
- Cardiovascular assessment including orthostatic vital signs 1, 3
Diagnostic Testing
Imaging
- MRI brain is preferred when central causes are suspected
- CT head has low sensitivity (~10%) for posterior fossa strokes but can exclude hemorrhage in emergency settings
- CT temporal bone is useful for assessing bony abnormalities in peripheral vertigo 4, 1
Laboratory Testing
- Selective use based on clinical suspicion:
- Complete blood count
- Electrolytes
- Glucose
- Thyroid function tests
- Vitamin B12 levels 1
Common Causes and Differentiation
| Condition | Clinical Presentation | Key Diagnostic Features |
|---|---|---|
| BPPV | Positional vertigo lasting seconds | Positive Dix-Hallpike test |
| Vestibular Neuritis | Sudden severe vertigo lasting days | Unidirectional horizontal nystagmus |
| Menière's Disease | Episodes with hearing loss, tinnitus, aural fullness | Characteristic audiometric findings |
| Vestibular Migraine | Variable duration, history of migraine | Photophobia, mild/absent hearing loss |
| Stroke/TIA | Sudden onset with neurological deficits | Abnormal HINTS exam |
Red Flags Requiring Urgent Evaluation
- Sudden severe headache
- New neurological symptoms
- Inability to walk or stand
- Persistent vomiting
- Altered mental status 1
Treatment Approaches
BPPV
- Canalith repositioning procedures (e.g., Epley maneuver) 3
Vestibular Neuritis
Pharmacotherapy
- Meclizine: 25-100 mg daily in divided doses for vertigo associated with vestibular system diseases 6
- Caution: May cause drowsiness; patients should avoid driving and alcohol
- Contraindicated in patients with hypersensitivity to meclizine
- Use with caution in patients with asthma, glaucoma, or prostate enlargement 6
Vestibular Rehabilitation Therapy
- First-line treatment for persistent dizziness
- Accelerates central compensation for vestibular imbalance 1
Common Pitfalls to Avoid
- Relying solely on symptom quality descriptions rather than timing and triggers
- Missing posterior circulation strokes
- Overreliance on CT imaging
- Excessive use of vestibular suppressant medications
- Failure to consider medication side effects as potential causes 1
Follow-up and Monitoring
- Reassess within 1 month after initial treatment
- Consider evaluation for persistent BPPV or underlying disorders if symptoms continue
- Educate patients about potential recurrence (15% per year for BPPV) 1
- Use validated assessment tools to track progress:
- Activities-Specific Balance Confidence Scale
- Dizziness Handicap Inventory
- Dynamic Gait Index
- Timed Up & Go test 1
The systematic approach to vertigo evaluation focuses on distinguishing between peripheral (usually benign) and central (potentially serious) causes through careful history-taking and targeted physical examination, with selective use of imaging and laboratory studies based on clinical suspicion.