What is the evaluation and treatment approach for a patient presenting with chronic dizziness?

Evaluation and Management of Chronic Dizziness

For chronic dizziness, focus your evaluation on timing, triggers, and associated symptoms to classify the syndrome, perform targeted bedside testing including Dix-Hallpike and nystagmus assessment, and reserve imaging only for red flags such as focal neurological deficits, asymmetric hearing loss, or central nystagmus patterns. 1, 2, 3

Initial Classification by Timing and Triggers

Classify chronic dizziness into one of four vestibular syndromes based on temporal patterns rather than the patient's subjective description:

• Triggered Episodic Vestibular Syndrome: Brief episodes (seconds to minutes) provoked by specific head movements, suggesting BPPV 2, 4
• Spontaneous Episodic Vestibular Syndrome: Recurrent episodes (minutes to hours) without positional triggers, suggesting Ménière's disease or vestibular migraine 1, 4
• Chronic Vestibular Syndrome: Persistent symptoms lasting weeks to months, suggesting incomplete compensation from prior vestibular injury or chronic disequilibrium 1, 3
• Acute Vestibular Syndrome: While not chronic, this represents acute persistent vertigo lasting days and should be distinguished from chronic presentations 2

Critical History Elements

Obtain specific details about symptom characteristics and associated features:

• Duration of each episode: Seconds suggests BPPV; minutes to hours suggests Ménière's or vestibular migraine; persistent suggests chronic vestibular syndrome 4, 3
• Positional triggers: Head movements triggering symptoms strongly suggest BPPV 2, 4
• Associated auditory symptoms: Unilateral hearing loss, tinnitus, or aural fullness suggests Ménière's disease 1, 3
• Migraine features: Headache, photophobia, phonophobia, or visual aura suggests vestibular migraine, which closely mimics Ménière's disease 1, 4
• Neurological symptoms: Diplopia, dysarthria, numbness, weakness, or difficulty walking suggests central causes requiring urgent evaluation 1, 2

Common pitfall: Vestibular migraine can present with auditory complaints that are bilateral and represent difficulty processing sound rather than true hearing loss, unlike Ménière's disease which causes unilateral sensorineural hearing loss 1

Physical Examination

Perform these specific bedside tests:

• Observe for spontaneous nystagmus in primary gaze and with fixation removed; central patterns (downbeating, direction-changing without gaze, purely vertical) indicate urgent neurological evaluation 1, 2, 3
• Dix-Hallpike maneuver for posterior canal BPPV and supine roll test for horizontal canal BPPV in patients with positional symptoms 2, 4, 3
• Complete otologic examination including assessment of hearing and tympanic membranes 4, 3
• Neurological examination focusing on gait, coordination, cranial nerves, and cerebellar signs 1, 3

Diagnostic Testing

Audiologic testing:

• Obtain comprehensive audiologic examination for patients with unilateral symptoms, persistent tinnitus, or reported hearing difficulties 1, 3
• This is essential to differentiate Ménière's disease (fluctuating low-frequency sensorineural hearing loss) from vestibular migraine (stable or absent hearing loss) 1

Imaging indications (MRI brain without contrast preferred):

• Unilateral tinnitus or asymmetric hearing loss to exclude vestibular schwannoma 1, 3
• Focal neurological deficits or abnormal neurological examination 1, 2
• Central nystagmus patterns (downbeating, direction-changing, purely vertical) 3
• Chronic disequilibrium with cerebellar ataxia signs to assess for cerebellar pathology 1
• Chronic disequilibrium with sensory ataxia signs: MRI cervical and thoracic spine to evaluate dorsal column pathology 1

Do NOT obtain imaging for:

• Nonspecific dizziness without vertigo, ataxia, or neurological deficits due to low diagnostic yield 1
• Clear peripheral vestibular syndromes (typical BPPV, vestibular neuritis with normal neurological exam) 1, 2

Treatment Approach by Diagnosis

BPPV (most common cause):

• Canalith repositioning procedures (Epley maneuver for posterior canal, barbecue roll for horizontal canal) 3, 5
• Imaging not indicated unless atypical features (lack of nystagmus on Dix-Hallpike or failure to respond to treatment) 1

Ménière's Disease:

• Salt restriction and diuretics as first-line management 3
• Intratympanic treatments (dexamethasone or gentamicin) for refractory cases 6
• MRI head and internal auditory canal with and without contrast to exclude vestibular schwannoma 1

Vestibular Migraine:

• Migraine prophylaxis (beta-blockers, calcium channel blockers, tricyclic antidepressants) and lifestyle modifications 3, 5
• Assess thoroughly for migraine history as this commonly mimics Ménière's disease 1

Chronic vestibular syndrome from incomplete compensation:

• Vestibular rehabilitation therapy is the cornerstone of treatment 5, 7
• Discontinue vestibular suppressants (meclizine, benzodiazepines) as they impede central compensation 7
• Address impediments to compensation: visual problems, proprioceptive deficits from neuropathy, psychological factors including fear of falling 7

Red Flags Requiring Urgent Evaluation

These findings mandate immediate neurological assessment and imaging:

• Focal neurological deficits (diplopia, dysarthria, weakness, numbness) 1, 3
• Inability to stand or walk 4, 3
• Central nystagmus patterns (downbeating, direction-changing without gaze change, purely vertical) 3
• Sudden unilateral hearing loss 4, 3
• Failure to respond to appropriate vestibular treatments 3
• High vascular risk factors (older age, hypertension, atrial fibrillation) with persistent symptoms 1

Common Pitfalls to Avoid

• Relying on patient's description of "dizziness type" rather than focusing on timing, triggers, and associated symptoms 2, 3
• Failing to perform Dix-Hallpike maneuver in patients with positional symptoms 2, 3
• Overusing imaging in patients with clear peripheral causes 2, 3
• Assuming normal neurological examination excludes stroke: Posterior circulation infarcts can present with isolated vertigo and normal exam 1
• Continuing vestibular suppressants in chronic dizziness, which impedes compensation 7
• Missing vestibular migraine by not thoroughly assessing migraine history 1