What is the initial approach to assessing and managing a patient presenting with dizziness?

Initial Approach to Assessing and Managing Dizziness

The initial approach to a patient with dizziness should focus on timing and triggers rather than symptom quality, with specific diagnostic maneuvers like the Dix-Hallpike test for vertigo and orthostatic vital signs to differentiate between common causes. 1, 2

Step 1: Categorize the Dizziness Based on Timing and Triggers

Categorize patients into one of three groups:

1. Acute Vestibular Syndrome (AVS) - Continuous dizziness lasting days

   • Perform HINTS examination (more sensitive than early MRI for stroke detection)
   • Differentiate between vestibular neuritis (peripheral) and stroke (central)

2. Spontaneous Episodic Vestibular Syndrome - Recurrent spontaneous episodes

   • Assess for associated symptoms to differentiate vestibular migraine from TIA
   • Note duration of episodes (minutes vs. hours)

3. Triggered Episodic Vestibular Syndrome - Episodes provoked by specific triggers

   • Perform Dix-Hallpike maneuver for positional vertigo
   • Supine roll test for horizontal canal BPPV

Step 2: Key Diagnostic Assessments

For all patients with dizziness:

• Determine if true vertigo is present: Ask if they experience rotation/spinning (vertigo) vs. lightheadedness/imbalance (non-vertiginous dizziness) 1

• Orthostatic vital signs: Especially important in elderly patients

  • Positive if BP drops ≥20 mmHg systolic or ≥10 mmHg diastolic within 3 minutes of standing 1

• Targeted physical examination:

  • Dix-Hallpike test for BPPV (most common cause at 42% in non-specialty settings)
  • Nystagmus assessment (direction, duration, fatigue)
  • Neurological examination for central causes

Step 3: Recognize Common Patterns

For Vertigo:

• BPPV: Brief vertigo with position changes, positive Dix-Hallpike test 1
• Vestibular neuritis: Sudden severe vertigo with prolonged nausea, no hearing loss 1
• Stroke/ischemia: Vertigo lasting minutes with severe imbalance, may include visual blurring and neurological symptoms 1
• Vestibular migraine: Attacks lasting hours to >24 hours, often with migraine history 1
• Labyrinthitis: Sudden severe vertigo with hearing loss, prolonged vertigo (>24 hours) 1

For Non-vertiginous Dizziness:

• Orthostatic hypotension: Lightheadedness upon standing
• Medication effects: Review medication list for potential causes
• Cardiovascular causes: Assess for arrhythmias, heart failure

Step 4: Initial Management

• For BPPV: Canalith Repositioning Procedure (Epley maneuver) - 80% success rate 1
• For Acute Vestibular Syndrome: Early corticosteroid therapy if peripheral cause confirmed 1
• For Orthostatic Hypotension: Medication adjustment, hydration, compression stockings, gradual position changes 1
• For Vestibular Neuritis: Supportive care, vestibular rehabilitation
• For Vertigo: Meclizine 25-100 mg daily in divided doses (only for vertigo associated with vestibular disease) 3

Pitfalls to Avoid

• Focusing on quality of dizziness rather than timing and triggers 1, 2, 4
• Failing to perform the Dix-Hallpike maneuver in patients with positional vertigo 1
• Routinely prescribing vestibular suppressants for BPPV 1
• Missing central causes by not performing the HINTS examination 1
• Ordering unnecessary imaging studies in patients with clear peripheral vertigo 1
• Overuse of meclizine, which can cause drowsiness and delay central compensation 3, 5
• Neglecting medication side effects as potential causes of dizziness

When to Consider Imaging

MRI brain (without contrast) is indicated for:

• Acute Vestibular Syndrome 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

Remember that the "timing and triggers" approach is more effective than the traditional symptom quality approach in distinguishing benign from dangerous causes of dizziness 2, 4.