What is the appropriate evaluation and management of a patient presenting with dizziness?

Evaluation of Dizziness

Initial Approach: Categorize by Timing and Triggers

The most critical first step is to classify dizziness into one of four vestibular syndromes based on timing and triggers, NOT on the patient's subjective description of symptoms, as this guides all subsequent management decisions 1, 2.

The four categories are:

• Brief episodic vertigo (seconds to minutes, triggered by head movements) 3
• Acute persistent vertigo (days to weeks, constant symptoms) 3
• Spontaneous episodic vertigo (recurrent episodes lasting minutes to hours) 1
• Chronic vestibular syndrome (persistent symptoms for months) 1

Key History Elements

Focus on these specific details rather than vague descriptions:

• Duration and onset: Seconds suggest BPPV; minutes to hours suggest Ménière's or vestibular migraine; days to weeks suggest vestibular neuritis or stroke 2, 4
• Triggers: Positional changes (BPPV), pressure changes (superior canal dehiscence), or no trigger (vestibular neuritis) 1, 2
• Associated symptoms:
  • Hearing loss, tinnitus, or aural fullness strongly suggest Ménière's disease 1, 2
  • Headache, photophobia, phonophobia suggest vestibular migraine 3
  • Neurological symptoms (diplopia, dysarthria, numbness, weakness) indicate central causes requiring urgent evaluation 2

Physical Examination

Essential Bedside Tests

• Observe for spontaneous nystagmus in all patients 2
• Dix-Hallpike maneuver and supine roll test for suspected BPPV 1, 2
• HINTS examination (Head Impulse, Nystagmus, Test of Skew) when acute vestibular syndrome is present with normal neurologic exam 3
• Orthostatic vital signs for patients with simple orthostatic dizziness without positional triggers 5

HINTS Examination Critical Point

When performed by trained practitioners, HINTS is more sensitive than early MRI for detecting posterior circulation stroke (100% vs 46%) 3. However, when performed by non-experts, results are less reliable 3.

Imaging Decisions: A Specific Algorithm

NO imaging indicated:

• Brief episodic vertigo with typical BPPV features (positive Dix-Hallpike, responds to Epley maneuver) 3
• Acute persistent vertigo with normal neurologic exam AND HINTS consistent with peripheral vertigo by trained examiner 3

MRI head without contrast is recommended:

• Acute persistent vertigo with abnormal neurologic examination 3
• HINTS examination suggesting central cause 3, 2
• High vascular risk patients with acute vestibular syndrome even if neurologic exam is normal 3
• Unilateral tinnitus, pulsatile tinnitus, or asymmetric hearing loss 1, 2

CT head without contrast (less sensitive alternative):

• May be appropriate before MRI in acute settings when stroke is suspected 3
• Critical caveat: Detection rate in isolated dizziness is extremely low (<1% in emergency department patients with normal neurologic exam) 3

MRI head and internal auditory canal with and without contrast:

• Chronic recurrent vertigo with unilateral hearing loss or tinnitus to exclude vestibular schwannoma 3

CT temporal bone without contrast:

• Suspected superior semicircular canal dehiscence 1

Red Flags Requiring Urgent Evaluation

These findings mandate immediate imaging and neurologic consultation 1, 2:

• Focal neurological deficits
• Sudden hearing loss
• Inability to stand or walk
• Downbeating nystagmus or other central nystagmus patterns
• Failure to respond to appropriate vestibular treatments
• New severe headache

Treatment Based on Diagnosis

BPPV (Most Common Cause)

Canalith repositioning procedures (Epley maneuver) are first-line treatment 3, 1, 4. No imaging or medication needed for typical cases.

Vestibular Neuritis

• Vestibular rehabilitation exercises 4
• Meclizine 25-100 mg daily in divided doses may be used for symptom relief 6, but avoid prolonged use as it impairs central compensation 4

Ménière's Disease

• Salt restriction and diuretics 1
• Intratympanic treatments for refractory cases 1

Vestibular Migraine

• Migraine prophylaxis and lifestyle modifications 1

Critical Pitfalls to Avoid

• Do NOT rely on patient's description of "spinning" vs "lightheadedness" - focus on timing and triggers instead 1, 2
• Do NOT assume normal neurologic exam excludes stroke - 75-80% of patients with acute vestibular syndrome from posterior circulation infarct have no focal neurologic deficits 3
• Do NOT order routine imaging for isolated dizziness - yield is only 4% and most findings are incidental 3
• Do NOT skip Dix-Hallpike testing in patients with brief episodic symptoms 2
• Do NOT use CT instead of MRI when stroke is suspected - CT misses many posterior circulation infarcts 3, 2
• Do NOT prescribe prolonged vestibular suppressants (like meclizine) as they delay central compensation 4