Standard Workup for Dizziness
The standard workup for dizziness should focus on timing and triggers rather than symptom quality, with mandatory components including orthostatic vital signs, the HINTS examination for acute vestibular syndrome, and the Dix-Hallpike test for positional vertigo. 1
Initial Assessment Framework
Step 1: Categorize by Timing and Triggers
Acute Vestibular Syndrome (AVS): Sudden onset, persistent dizziness lasting days
- Perform HINTS exam (Head-Impulse, Nystagmus, Test of Skew) - more sensitive than early MRI for stroke detection 1
- Normal HINTS suggests peripheral cause (vestibular neuritis)
- Abnormal HINTS suggests central cause (stroke) requiring urgent evaluation
Spontaneous Episodic Vestibular Syndrome: Recurrent episodes without clear trigger
- Evaluate for associated symptoms (hearing loss, tinnitus, aural fullness suggest Menière's disease)
- Assess for history of migraine (suggests vestibular migraine)
- Rule out TIA if vascular risk factors present
Triggered Episodic Vestibular Syndrome: Dizziness provoked by specific triggers
Step 2: Essential Physical Examination Components
- Orthostatic vital signs (mandatory) - diagnostic for orthostatic hypotension if BP drops ≥20 mmHg systolic or ≥10 mmHg diastolic within 3 minutes of standing 1
- Detailed neurological examination
- Cardiovascular assessment
- Vestibular examination including:
- Nystagmus assessment (direction, duration, triggers)
- HINTS examination for acute vestibular syndrome
- Dix-Hallpike test for positional vertigo
Diagnostic Testing
Laboratory Testing
- Generally not required for most cases of dizziness 2, 3
- Consider based on clinical suspicion:
- CBC if anemia suspected
- Electrolytes, glucose if metabolic causes suspected
- Thyroid function tests if thyroid dysfunction suspected
Imaging
- Not routinely indicated for clear peripheral vertigo 1, 3
- MRI brain (without contrast) indicated for:
- Acute vestibular syndrome with abnormal HINTS exam
- Neurological deficits
- High vascular risk patients with acute vestibular syndrome
- Chronic undiagnosed dizziness not responding to treatment 1
Specialized Testing
- Audiometry - if hearing loss is present (especially for suspected Menière's disease)
- Consider referral for vestibular testing for unclear or persistent cases
Management Based on Diagnosis
- BPPV: Canalith Repositioning Procedure (Epley maneuver) - 80% success rate 1
- Vestibular Neuritis: Early corticosteroid therapy, vestibular rehabilitation 1
- Orthostatic Hypotension: Medication adjustment, hydration, compression stockings 1
- Menière's Disease: Salt restriction, diuretics 2
- Vertigo: Meclizine 25-100 mg daily in divided doses for symptomatic relief 4
Common Pitfalls to Avoid
- Focusing on quality of dizziness rather than timing and triggers 1, 5
- Failing to perform the Dix-Hallpike maneuver in patients with positional vertigo 1
- Missing central causes by not performing the HINTS examination 1
- Routinely prescribing vestibular suppressants for BPPV (delays central compensation) 1
- Ordering unnecessary imaging studies in patients with clear peripheral vertigo 1, 3
- Overlooking medication causes, especially in elderly patients (diuretics, β-blockers, calcium antagonists, ACE inhibitors, nitrates, antipsychotics, tricyclic antidepressants, antihistamines) 1
Validated Assessment Tools
- Activities-Specific Balance Confidence Scale
- Dizziness Handicap Inventory
- Dynamic Gait Index
- Timed Up & Go test 1
The modern approach to dizziness evaluation has shifted from the traditional symptom quality-based assessment (vertigo, presyncope, disequilibrium, light-headedness) to a more clinically useful timing and triggers framework that better distinguishes between benign peripheral and potentially dangerous central causes 1, 5.