What is the initial approach for a patient presenting with vertigo?

Initial Approach to Patients with Vertigo

The initial approach to a patient with vertigo should focus on categorizing the vertigo into one of four vestibular syndromes (Acute Vestibular Syndrome, Triggered Episodic Vestibular Syndrome, Spontaneous Episodic Vestibular Syndrome, or Chronic Vestibular Syndrome) and distinguishing between peripheral and central causes through targeted history and physical examination. 1

Step 1: Identify Red Flags Requiring Urgent Evaluation

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

Step 2: Categorize the Vertigo Based on Timing and Triggers

Acute Vestibular Syndrome (AVS)

• Continuous vertigo lasting days
• Often accompanied by nausea, vomiting, and gait instability
• Common causes: Vestibular neuritis (peripheral) or stroke (central)

Triggered Episodic Vestibular Syndrome

• Brief episodes triggered by specific movements
• Most common cause: Benign Paroxysmal Positional Vertigo (BPPV)

Spontaneous Episodic Vestibular Syndrome

• Recurrent episodes without clear triggers
• Common causes: Menière's disease, vestibular migraine

Chronic Vestibular Syndrome

• Persistent unsteadiness or imbalance
• Common cause: Bilateral vestibular hypofunction 1, 2

Step 3: Perform Targeted Physical Examination

For Acute Vestibular Syndrome (AVS)

• HINTS examination (highly sensitive for stroke detection):
  • Head Impulse test: Abnormal in peripheral causes, normal in central causes
  • Nystagmus evaluation: Direction-changing or vertical nystagmus suggests central cause
  • Test of Skew: Vertical misalignment suggests central cause
  • + Hearing assessment: Sudden hearing loss with vertigo suggests peripheral cause 1, 3

For Triggered Episodic Vestibular Syndrome

• Dix-Hallpike maneuver: Gold standard for diagnosing posterior canal BPPV
  • Positive test shows torsional, upbeating nystagmus
• Supine roll test: Used for lateral semicircular canal BPPV 1

General Neurological Examination

• Assess for limb weakness, dysmetria, ataxia
• Note: Normal neurological exam does not rule out central causes 1, 3

Step 4: Consider Imaging Based on Clinical Findings

Indications for MRI Brain (without contrast):

• AVS with abnormal HINTS examination
• AVS with neurological deficits
• High vascular risk patients with AVS even with normal examination
• Chronic undiagnosed dizziness not responding to treatment 1

Other Imaging Considerations:

• CT temporal bone: For suspected bony abnormalities
• MRA Head and Neck: When vertebrobasilar insufficiency is suspected 1

Step 5: Initial Management

For BPPV:

• Canalith Repositioning Procedures (e.g., Epley maneuver)
  • Success rates around 80% with 1-3 treatments 1

For Vestibular Neuritis:

• Vestibular rehabilitation
• Consider short-term symptomatic treatment 1

For Symptomatic Relief:

• Meclizine: 25-100 mg daily in divided doses
  • Indicated for vertigo associated with vestibular system diseases
  • Caution: May cause drowsiness and has anticholinergic effects
  • Not recommended for routine BPPV treatment 1, 4

Important Considerations and Pitfalls

Common Diagnostic Pitfalls:

• Missing central causes: HINTS examination is more sensitive than CT for detecting posterior circulation stroke 1, 3
• Overreliance on symptom quality: Modern approach focuses on triggers and timing rather than just describing the sensation 2
• Excessive use of vestibular suppressants: These can delay central compensation 1

Special Populations:

• Elderly patients: Have 12-fold increased risk of falls with vestibular disorders
  • Medication review is crucial (sedatives, antihypertensives, muscle relaxants)
  • Fall prevention strategies should be implemented 1

Follow-up Recommendations:

• Reassessment within 1 month after initial treatment
• Education about potential recurrence (15% per year for BPPV)
• Use validated assessment tools to track progress 1

Remember that while most cases of vertigo are benign (BPPV, vestibular neuronitis, Menière's disease), central causes like stroke must always be considered, especially in the presence of neurological signs or abnormal HINTS examination 5, 6.