What is the initial workup for a patient presenting with dizziness?

Initial Workup for Dizziness

The initial workup for dizziness should focus on timing and triggers rather than the specific descriptor the patient uses, with particular attention to distinguishing between peripheral and central causes through targeted history and physical examination. 1, 2

Step 1: Categorize the Dizziness Pattern

• Categorize based on timing and triggers rather than subjective descriptions 1, 2:
  • Acute vestibular syndrome: acute persistent continuous dizziness lasting days to weeks with nausea, vomiting, and head motion intolerance 1
  • Triggered episodic vestibular syndrome: episodic dizziness triggered by specific actions (usually position changes) lasting <1 minute 1
  • Spontaneous episodic vestibular syndrome: episodic dizziness without triggers lasting minutes to hours 1
  • Chronic vestibular syndrome: dizziness lasting weeks to months or longer 1

Step 2: Focused History

• Determine if symptoms represent true vertigo (rotation/spinning) versus other forms of dizziness (lightheadedness, disequilibrium) 2
• Inquire about associated symptoms that suggest specific diagnoses 2:
  • Hearing loss, tinnitus, or aural fullness (suggests Ménière's disease) 2
  • Neurological symptoms (suggests central cause) 1
  • Medication side effects 1
  • Recent trauma 1
• Evaluate for "alarming symptoms" suggesting serious pathology 2:
  • Syncope during exertion or in lying position 2
  • Family history of sudden cardiac death 2
  • Slow recovery from syncope 2

Step 3: Physical Examination

• Perform a complete neurological examination to assess for focal deficits 2
• Check orthostatic vital signs 3
• Assess for nystagmus (direction, duration, triggers) 2
• Perform specific maneuvers based on dizziness pattern:
  • For triggered episodic vestibular syndrome: Dix-Hallpike maneuver to evaluate for BPPV 1, 2
  • For lateral canal BPPV: Supine roll test 1
  • For acute vestibular syndrome: HINTS examination (Head-Impulse, Nystagmus, Test of Skew) 2, 4

Step 4: HINTS Examination (for Acute Vestibular Syndrome)

• Head Impulse Test: Abnormal response (catch-up saccade) suggests peripheral cause; normal response raises concern for central cause 4
• Nystagmus Assessment: Direction-changing nystagmus suggests central cause; unidirectional horizontal nystagmus suggests peripheral cause 4
• Test of Skew: Vertical misalignment suggests central lesion 4
• HINTS has greater sensitivity than early MRI for detecting stroke when performed correctly 4

Step 5: Diagnostic Testing

• Laboratory testing is usually not required but can be helpful in selected cases 3
• Do not routinely order imaging for patients who meet diagnostic criteria for BPPV unless there are additional concerning signs/symptoms 2
• Consider MRI with diffusion-weighted imaging for 1, 2:
  • Acute persistent vertigo with neurological deficits 2
  • HINTS examination suggesting central pathology 2
  • Risk factors for stroke 2

Common Pitfalls to Avoid

• Over-reliance on symptom quality descriptions rather than timing and triggers 2, 5
• Routine use of vestibular suppressant medications for BPPV, which may delay recovery 2
• Failure to recognize that 25-50% of patients with recurrent BPPV may have associated vestibular pathology requiring additional evaluation 2
• Not considering that stroke can present with isolated dizziness without other neurological symptoms in approximately 11% of cases 2

Differential Diagnosis

• Peripheral causes (generally less concerning but can cause significant morbidity) 3:
  • Benign paroxysmal positional vertigo (BPPV) 1
  • Vestibular neuritis 1
  • Ménière's disease 1, 2
  • Labyrinthitis 1
• Central causes (more urgent) 3:
  • Posterior circulation stroke/TIA 1, 2
  • Vestibular migraine 1
  • Demyelinating diseases 1
  • Central nervous system lesions 1
• Other causes:
  • Medication side effects 1
  • Anxiety or panic disorder 1
  • Postural hypotension 1
  • Cervicogenic vertigo 1