What is the diagnostic approach for vertigo?

Diagnostic Approach for Vertigo

The diagnosis of vertigo should be based primarily on a structured assessment focusing on timing, triggers, and associated symptoms, with the Dix-Hallpike maneuver as the gold standard test for the most common cause, benign paroxysmal positional vertigo (BPPV). 1

Key Diagnostic Steps

1. History Assessment

• Timing and duration of symptoms:

  • BPPV: Brief episodes lasting seconds to minutes 2, 1
  • Vestibular neuritis: Sudden severe vertigo lasting days 1
  • Vestibular migraine: Attacks lasting hours to >24 hours 1
  • Stroke/ischemia: Minutes with severe imbalance 1

• Triggers:

  • Positional changes (rolling over in bed, looking up, bending forward) suggest BPPV 2
  • Spontaneous onset suggests vestibular neuritis or stroke 1

• Associated symptoms:

  • Hearing loss, tinnitus: May indicate Ménière's disease or labyrinthitis 1
  • Neurological symptoms: Suggest central causes requiring urgent evaluation 1
  • Photophobia: Common with vestibular migraine 1

2. Physical Examination

Dix-Hallpike Maneuver (Critical for BPPV Diagnosis)

1. Position the patient seated upright
2. Rotate the patient's head 45 degrees to the side being tested
3. Quickly move the patient from seated to supine position with head hanging 20 degrees below horizontal
4. Observe for nystagmus and vertigo 2

Positive Dix-Hallpike test for posterior canal BPPV includes:

• Latency period (typically 5-20 seconds) between maneuver completion and onset of vertigo/nystagmus
• Vertigo and nystagmus that increase and resolve within 60 seconds
• Characteristic torsional, upbeating nystagmus 2

Other Essential Examination Elements

• HINTS examination (Head Impulse, Nystagmus, Test of Skew) to differentiate peripheral from central causes 1
• Neurological examination to identify focal deficits suggesting central pathology 1
• Cardiovascular assessment including heart rate, rhythm, and orthostatic vitals 1

Diagnostic Classification

1. Peripheral vs. Central Vertigo

• Peripheral vertigo (inner ear origin):

  • Nystagmus that lessens with visual fixation
  • No associated neurological deficits
  • Often positional or triggered by head movement 3

• Central vertigo (brain origin):

  • Nystagmus that persists despite visual fixation
  • May have associated neurological symptoms
  • Often spontaneous or constant 3

2. Classification by Vestibular Syndrome

• Triggered episodic vestibular syndrome (e.g., BPPV)
• Spontaneous episodic vestibular syndrome (e.g., Ménière's, vestibular migraine)
• Acute vestibular syndrome (e.g., vestibular neuritis, stroke) 4

Diagnostic Testing

When to Consider Imaging

• MRI brain is indicated for:

  • Acute vestibular syndrome with abnormal HINTS exam
  • Presence of neurological deficits
  • High vascular risk patients with acute vestibular syndrome
  • Chronic undiagnosed dizziness not responding to treatment 1

• CT scan is generally not indicated for isolated vertigo without focal neurological deficits 1

Common Pitfalls to Avoid

• Focusing on quality of dizziness rather than timing and triggers
• Failing to perform the Dix-Hallpike maneuver in patients with positional vertigo
• Missing central causes by not performing the HINTS examination
• Ordering unnecessary imaging for clear peripheral vertigo 1

Validated Assessment Tools

For quantifying impact and monitoring progress:

• Activities-Specific Balance Confidence Scale
• Dizziness Handicap Inventory
• Dynamic Gait Index
• Timed Up & Go test 1

By following this structured diagnostic approach, clinicians can effectively differentiate between the various causes of vertigo and determine appropriate management strategies to improve patient outcomes.