What is the recommended management for a patient with dizziness and shakiness upon waking, with a negative CT brain scan for bleeding and no ear infection?

Management of Dizziness and Shakiness Upon Waking with Negative CT Brain and No Ear Infection

For patients with dizziness and shakiness upon waking with a negative CT brain scan for bleeding and no ear infection, MRI brain imaging is strongly recommended as the next diagnostic step, as CT has very low sensitivity (<1%) for detecting causes of isolated dizziness. 1

Diagnostic Approach

Initial Assessment

• Isolated dizziness (without vertigo, ataxia, or other neurologic deficits) accounts for approximately 2.5% of emergency department presentations 1
• CT brain has very low diagnostic yield (<1%) for isolated dizziness, despite having high negative predictive value (90%) 1
• MRI with diffusion-weighted imaging has higher sensitivity (4%) than CT for detecting causes of dizziness 1

Key Clinical Considerations

• Symptoms upon waking require evaluation for:
  • Orthostatic hypotension (common cause of morning dizziness) 1
  • Positional vertebrobasilar insufficiency 2
  • Sleep-related breathing disorders 2
  • Medication side effects (review medication list for vestibular suppressants, antihypertensives) 3

Recommended Diagnostic Tests

• MRI head and internal auditory canal without IV contrast, or without and with IV contrast (preferred over CT for isolated dizziness) 1
• Orthostatic blood pressure measurement to assess for hypotension 3, 4
• Consider electroencephalogram if symptoms persist despite negative imaging 2

Management Algorithm

Step 1: Evaluate for Common Benign Causes

• Assess for orthostatic hypotension with positional blood pressure measurements 4
• Perform Dix-Hallpike maneuver to evaluate for benign paroxysmal positional vertigo (BPPV) 1, 5
• Review medication list for potential causes of dizziness 3

Step 2: Consider Advanced Imaging

• If initial evaluation is unrevealing, proceed to MRI brain with diffusion-weighted imaging 1
• Consider MRA head and neck if vascular etiology is suspected 1

Step 3: Treatment Based on Etiology

• For orthostatic hypotension: hydration, salt intake, compression stockings, medication adjustment 3
• For BPPV: canalith repositioning procedures (Epley maneuver) 1, 5
• For vestibular neuritis: vestibular rehabilitation exercises 5
• For anxiety or psychiatric causes: appropriate mental health referral 4

Important Caveats

• Morning dizziness can be a symptom of autonomic dysfunction, even if symptoms don't appear orthostatic 1
• Lightheadedness related to systemic causes (dehydration, hypotension, vasovagal reaction, anxiety) often doesn't require neuroimaging 1, 6
• A final diagnosis is not obtained in approximately 20% of dizziness cases 3
• Persistent symptoms despite negative imaging warrant further investigation and specialist referral 7

Red Flags Requiring Urgent Evaluation

• New neurological deficits accompanying dizziness 2
• Severe, sudden-onset vertigo with hearing loss 1
• Symptoms associated with headache, especially new or different headache 5
• Symptoms that worsen with position changes but don't resolve 1