What is the approach to a patient presenting with dizziness?

Approach to Dizziness

Categorize dizziness by timing and triggers—not by the patient's vague description—into one of four vestibular syndromes to guide your diagnostic workup and avoid missing life-threatening causes like stroke. 1

Initial Categorization by Timing and Triggers

The American Academy of Otolaryngology-Head and Neck Surgery framework divides dizziness into four syndromes based on temporal patterns 1, 2:

• Acute Vestibular Syndrome (AVS): Acute persistent dizziness lasting days to weeks with continuous symptoms 1
• Triggered Episodic Vestibular Syndrome: Brief episodes provoked by specific head movements or position changes 1, 3
• Spontaneous Episodic Vestibular Syndrome: Recurrent episodes without positional triggers 1, 3
• Chronic Vestibular Syndrome: Persistent symptoms lasting months 2

Critical pitfall: Do not rely on patient descriptions of "spinning" versus "lightheadedness"—these subjective terms are unreliable and do not distinguish benign from dangerous causes 4, 3. Duration and triggers are far more diagnostically useful 1.

Key History Elements to Elicit

Focus your questioning on these specific details 1, 2:

• Duration of individual episodes: Seconds (BPPV), minutes to hours (vestibular migraine, Ménière's), days (vestibular neuritis, stroke) 4
• Positional triggers: Head turning or lying down suggests BPPV 4, 1
• Associated otologic symptoms: Hearing loss, tinnitus, or aural fullness point toward Ménière's disease 4, 2
• Neurologic red flags: Headache, diplopia, dysarthria, numbness, weakness, or dysphagia suggest central causes 4, 1
• Cardiovascular symptoms: Lightheadedness with standing or exertion may indicate orthostatic hypotension or cardiac causes 4, 5

In heart failure patients on guideline-directed medical therapy (GDMT), mild dizziness upon standing is often a benign side effect of life-prolonging medications and does not require dose reduction if the patient is otherwise stable 4.

Physical Examination Protocol

For All Patients

• Observe for spontaneous nystagmus at rest and with gaze holding 1, 2
• Perform complete neurologic examination looking for focal deficits 4, 1

For Triggered Episodic Symptoms (Suspected BPPV)

• Dix-Hallpike maneuver: Tests posterior semicircular canal 4, 1
• Supine roll test: Tests horizontal semicircular canal 1, 3

Critical point: Typical BPPV with characteristic nystagmus on Dix-Hallpike testing requires no imaging 4.

For Acute Vestibular Syndrome (AVS)

• HINTS examination (Head Impulse, Nystagmus, Test of Skew) when performed by trained practitioners is more sensitive than early MRI for detecting stroke (100% vs 46%) 4, 6
• Dangerous finding: A normal head impulse test, direction-changing nystagmus, or skew deviation suggests central (stroke) rather than peripheral cause 4, 5

Major pitfall: 11-25% of patients with AVS have posterior circulation stroke, and up to 75% of these lack focal neurologic deficits 4. A normal neurologic exam does not exclude stroke in AVS 4, 3.

Imaging Decisions

When Imaging is NOT Indicated

• Typical BPPV with characteristic positional nystagmus 4
• AVS with complete HINTS triad consistent with peripheral vertigo 4
• Stable heart failure patients on GDMT with mild orthostatic dizziness 4

When to Order MRI Brain (Preferred Over CT)

• AVS with HINTS examination suggesting central cause 4, 1
• Focal neurologic deficits present 4, 2
• Unilateral or pulsatile tinnitus 2
• Asymmetric hearing loss 2
• Failure to respond to appropriate vestibular treatments 2
• Downbeating or other central nystagmus patterns 2

Evidence note: CT imaging in emergency departments detects contributory CNS pathology in less than 1% of patients with dizziness and normal neurologic examination 4. MRI with diffusion-weighted imaging is far superior for detecting posterior circulation stroke 4, 1.

Common Diagnoses and Management

Benign Paroxysmal Positional Vertigo (BPPV)

• Treatment: Canalith repositioning procedures (Epley maneuver for posterior canal) 4, 2
• Recurrence risk: 10-18% at 1 year, up to 36% long-term 4
• Patient education: Counsel about fall risk and symptom recurrence 4

Vestibular Neuritis/Labyrinthitis

• Presentation: Acute prolonged vertigo lasting 12-36 hours with gradual improvement over days 4
• Distinguishing feature: Vestibular neuritis has no hearing loss; labyrinthitis includes hearing loss 4

Ménière's Disease

• Diagnostic criteria: Episodic vertigo lasting 20 minutes to 12 hours with fluctuating hearing loss, tinnitus, or aural fullness 4
• Management: Salt restriction, diuretics, intratympanic treatments for refractory cases 2

Vestibular Migraine

• Presentation: Episodes lasting minutes to hours, often with migraine history, photophobia more common than visual aura 4
• Management: Migraine prophylaxis and lifestyle modifications 2

Medication Considerations

Meclizine 25-100 mg daily is FDA-approved for vertigo associated with vestibular system diseases 7. However, it causes drowsiness and has anticholinergic effects; use with caution in patients with asthma, glaucoma, or prostatic enlargement 7.

Red Flags Requiring Urgent Evaluation

Refer immediately or obtain urgent imaging for 2:

• Focal neurologic deficits
• Sudden hearing loss
• Inability to stand or walk
• Downbeating nystagmus or central nystagmus patterns
• HINTS examination suggesting central cause in AVS