What are the diagnosis and treatment options for dizziness with tinnitus?

Dizziness with Tinnitus: Diagnosis and Treatment

The combination of dizziness and tinnitus most commonly suggests Ménière's disease when accompanied by episodic vertigo lasting 20 minutes to 24 hours, fluctuating hearing loss, and aural fullness—this requires a clinical diagnosis based on symptom pattern, audiometry, and exclusion of other causes through targeted imaging only when specific red flags are present. 1

Diagnostic Approach

Critical History Elements

You must determine if the patient has true vertigo (spinning sensation) versus vague dizziness, as this distinction is essential for diagnosis. 1

Ask these specific questions to establish the diagnosis:

• Duration of dizzy episodes: Ménière's disease causes vertigo lasting 20 minutes to 24 hours, not seconds (which suggests BPPV) 1
• Timing of tinnitus relative to vertigo: In Ménière's disease, tinnitus and aural fullness occur immediately before, during, or after vertigo attacks 1
• Hearing fluctuation: Does hearing abruptly change, alternating between worsening and improving? 1
• Positional triggers: Vertigo provoked by head position suggests BPPV, not Ménière's disease 1
• Associated symptoms: Headache with photophobia suggests vestibular migraine; neurologic symptoms suggest stroke 1

Physical Examination Priorities

• Otoscopic examination to identify vascular retrotympanic masses or middle ear pathology 2
• Neurologic examination to detect focal deficits that would suggest central causes 1
• Dix-Hallpike maneuver if positional symptoms are present 3
• HINTS examination (head-impulse, nystagmus, test of skew) for acute vestibular syndrome to differentiate peripheral from central causes 1

Diagnostic Testing Algorithm

Order audiometry for all patients with unilateral tinnitus, persistent symptoms ≥6 months, or hearing difficulties. 2

Imaging is NOT routinely indicated unless specific red flags are present:

• Unilateral or asymmetric tinnitus 1, 2
• Pulsatile tinnitus (almost always requires imaging) 1, 2, 4
• Focal neurologic abnormalities 2
• Asymmetric hearing loss 2

When imaging is indicated, obtain MRI of the internal auditory canal with contrast to exclude vestibular schwannoma and other CPA lesions. 1

Additional testing for Ménière's disease may include:

• Video/electronystagmography to evaluate vestibular function (takes ~1 hour, may provoke vertigo) 1
• Electrocochleography to measure cochlear electrical responses 1

Treatment Approach

For Confirmed or Suspected Ménière's Disease

There is no cure for Ménière's disease; treatment focuses on symptom management and preventing attacks. 1

Acute vertigo episodes can be treated with meclizine, which is FDA-approved for vertigo associated with vestibular system diseases. 5

For Persistent Bothersome Tinnitus (Regardless of Cause)

Cognitive Behavioral Therapy (CBT) has the strongest evidence for improving quality of life in patients with persistent, bothersome tinnitus and should be recommended. 2, 4, 6

Hearing aids should be recommended for patients with any degree of hearing loss and tinnitus, even if hearing loss is mild or unilateral. 2, 4

Education and counseling about tinnitus management strategies are essential for all patients. 2

Treatments to AVOID

Do NOT routinely prescribe antidepressants, anticonvulsants, anxiolytics, or intratympanic medications for tinnitus, as evidence is insufficient and side effects may worsen symptoms. 2, 4

Do NOT recommend dietary supplements (Ginkgo biloba, melatonin, zinc) as they lack consistent evidence of benefit. 2, 4

Critical Pitfalls to Avoid

• Missing pulsatile tinnitus: This almost always requires vascular imaging (CTA or MRA) to identify treatable vascular abnormalities 1, 2, 4
• Overlooking psychiatric comorbidity: Patients with severe anxiety or depression require prompt intervention due to increased suicide risk in tinnitus patients 2, 4
• Misdiagnosing vestibular migraine as Ménière's disease: Vestibular migraine attacks may be shorter or longer than 20 minutes-24 hours, hearing loss is less common, and patients typically have migraine history with photophobia 1
• Ordering unnecessary imaging: Bilateral non-pulsatile tinnitus without neurologic findings does NOT require imaging 1, 2
• Assuming all dizziness is vertigo: Many elderly patients with Ménière's disease may describe vague dizziness rather than frank spinning, but lightheadedness or presyncope suggests non-vestibular causes 1