What is the appropriate workup for a patient presenting with vertigo (dizziness)?

From the Guidelines

A vertigo workup should begin with a thorough history and physical examination to distinguish peripheral from central causes, and key diagnostic tests include the Dix-Hallpike maneuver for benign paroxysmal positional vertigo (BPPV) as recommended by 1. The Dix-Hallpike maneuver is a crucial test for diagnosing posterior semicircular canal BPPV, and it should be performed by bringing the patient from an upright to supine position with the head turned 45° to one side and neck extended 20° with the affected ear down, as stated in 1. Some key points to consider in the workup include:

• Differentiating BPPV from other causes of imbalance, dizziness, and vertigo, as recommended by 1
• Assessing patients with BPPV for factors that modify management, including impaired mobility or balance, central nervous system disorders, a lack of home support, and/or increased risk for falling, as stated in 1
• Not obtaining radiographic imaging in a patient who meets diagnostic criteria for BPPV in the absence of additional signs and/or symptoms inconsistent with BPPV that warrant imaging, as recommended by 1 and 1
• Not ordering vestibular testing in a patient who meets diagnostic criteria for BPPV in the absence of additional vestibular signs and/or symptoms inconsistent with BPPV that warrant testing, as stated in 1 and 1
• Treating patients with posterior canal BPPV with a canalith repositioning procedure, as recommended by 1
• Not recommending postprocedural postural restrictions after canalith repositioning procedure for posterior canal BPPV, as stated in 1
• Offering observation with follow-up as initial management for patients with BPPV, as recommended by 1
• Considering vestibular rehabilitation, either self-administered or with a clinician, in the treatment of BPPV, as stated in 1
• Not routinely treating BPPV with vestibular suppressant medications such as antihistamines and/or benzodiazepines, as recommended by 1
• Reassessing patients within 1 month after an initial period of observation or treatment to document resolution or persistence of symptoms, as stated in 1
• Evaluating patients with persistent symptoms for unresolved BPPV and/or underlying peripheral vestibular or central nervous system disorders, as recommended by 1
• Educating patients regarding the impact of BPPV on their safety, the potential for disease recurrence, and the importance of follow-up, as stated in 1

From the Research

Initial Evaluation of Vertigo

The initial evaluation of a patient presenting with vertigo involves determining whether the patient has a peripheral or central cause of vertigo 2. This distinction is crucial as central causes of vertigo can be more serious and require further work-up with laboratory and radiologic studies such as magnetic resonance imaging.

Clinical Presentations and Diagnostic Tests

Knowing the typical clinical presentations of the various causes of vertigo aids in making this distinction 2. The history and physical examination, including special tests such as the Dix-Hallpike maneuver, provide important clues to the diagnosis 2, 3. Associated neurologic signs and symptoms, such as nystagmus that does not lessen when the patient focuses, point to central causes of vertigo 2.

Management of Benign Paroxysmal Positional Vertigo (BPPV)

BPPV is a common cause of acute vertigo or dizziness in patients presenting to an emergency department 4. The most efficient management of BPPV is to perform a bedside test (Dix-Hallpike test) and then to treat the patients with a bedside positional (the Epley) maneuver 4, 5. This approach reduces resource utilization, ED length of stay, and use of ineffective medications 4.

Key Components of the Workup

The workup for a patient presenting with vertigo should include:

• A thorough history and physical examination, including special tests such as the Dix-Hallpike maneuver 2, 3
• Assessment for nystagmus and other neurologic signs and symptoms 2, 6
• Orthostatic blood pressure measurement and a full cardiac and neurologic examination 6
• Laboratory testing and imaging as needed, although these are usually not required 6
• Consideration of canalith repositioning procedures (e.g., Epley maneuver) for benign paroxysmal positional vertigo 4, 5, 6
• Vestibular rehabilitation for many peripheral and central etiologies 6