What is the approach to diagnose vertigo?

Diagnostic Approach to Vertigo

The diagnosis of vertigo requires a structured approach focusing on timing, triggers, and associated symptoms, with the Dix-Hallpike test being the gold standard diagnostic maneuver for the most common cause, Benign Paroxysmal Positional Vertigo (BPPV). 1

Distinguishing Vertigo from Other Forms of Dizziness

First, determine if the patient is experiencing true vertigo (rotational or spinning sensation) versus non-vertiginous dizziness:

Feature	Vertigo	Dizziness (Non-vertiginous)
Sensation	Rotational or spinning	Lightheadedness, floating, imbalance
Duration	Usually brief (seconds to minutes) for BPPV; hours to days for other causes	Variable
Triggers	Often positional changes (BPPV)	Often standing, exertion, medications
Nystagmus	Present with peripheral causes	Usually absent
Associated symptoms	May have hearing loss, tinnitus (Ménière's)	May have palpitations, visual changes

1

Key History Elements

Focus on these critical aspects:

• Timing and duration:

  • Seconds to minutes: Suggests BPPV
  • 20 minutes to 24 hours: Consider Ménière's disease
  • Hours to days: May indicate vestibular neuritis
  • Minutes with neurological symptoms: Consider stroke/TIA

• Triggers:

  • Positional changes (rolling in bed, looking up): Classic for BPPV
  • No clear trigger with sudden onset: Consider vestibular neuritis or stroke

• Associated symptoms:

  • Hearing loss, tinnitus, ear fullness: Suggests Ménière's disease or labyrinthitis
  • Headache, photophobia: Consider vestibular migraine
  • Neurological deficits: Warrants urgent evaluation for stroke 1

Physical Examination

Dix-Hallpike Maneuver (Critical for BPPV Diagnosis)

Proper technique:

1. Position patient seated upright
2. Rotate patient's head 45 degrees to the side being tested
3. Quickly move patient from seated to supine position with head hanging 20 degrees below horizontal
4. Observe for:
   • Nystagmus (typically after 5-20 second latency)
   • Subjective vertigo
   • Resolution within 60 seconds 2, 1

The test must be performed bilaterally to determine which ear is affected. A positive test shows characteristic nystagmus and vertigo that increases and resolves within 60 seconds. 2

Additional Examination Elements

• Neurological examination: Look for central signs (nystagmus that doesn't lessen with fixation, other neurological deficits)
• HINTS examination: (Head Impulse, Nystagmus, Test of Skew) - critical for distinguishing peripheral from central causes in acute vestibular syndrome
• Cardiovascular examination: Check for orthostatic changes, carotid bruits, arrhythmias 1

Common Diagnostic Patterns

Peripheral Causes (Most Common)

1. BPPV:

   • Brief vertigo with position changes
   • Positive Dix-Hallpike test
   • No hearing loss or tinnitus 1

2. Vestibular Neuritis:

   • Sudden severe vertigo lasting days
   • Unidirectional horizontal nystagmus
   • No hearing loss or neurological symptoms 1

3. Ménière's Disease:

   • Episodes lasting 20 minutes to 24 hours
   • Fluctuating hearing loss, tinnitus, ear fullness 1

Central Causes (Less Common but More Serious)

1. Stroke/TIA:

   • Vertigo with neurological symptoms
   • Abnormal HINTS examination
   • May have risk factors for cerebrovascular disease 1, 3

2. Vestibular Migraine:

   • Attacks lasting hours to >24 hours
   • Often history of migraine
   • More photophobia 1

Common Pitfalls to Avoid

• Focusing on the 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 studies in clear peripheral vertigo
• Not repeating the Dix-Hallpike test if initially negative (may need to test horizontal canals and then repeat posterior canal testing) 1, 4

When to Consider Imaging

MRI brain (without contrast) is indicated in:

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

CT scans are not routinely indicated for isolated vertigo without focal neurological deficits but should be performed when vertigo is accompanied by severe headache, age >60 years, vomiting, trauma, seizures, or focal neurological deficits. 1

Remember that stroke accounts for 3-7% among all causes of vertigo, and careful evaluation is necessary to avoid missing this potentially serious diagnosis. 3