What is the initial management for a patient presenting with dizziness?

Initial Management of Dizziness

Focus on timing and triggers rather than the patient's subjective description to categorize dizziness into specific vestibular syndromes, which will guide all subsequent diagnostic and therapeutic decisions. 1, 2

Immediate Categorization by Timing Pattern

The first step is to classify dizziness into one of four vestibular syndromes based on temporal characteristics 1, 2, 3:

• Acute Vestibular Syndrome (AVS): Acute persistent dizziness lasting days to weeks with constant symptoms 1, 2
• Triggered Episodic Vestibular Syndrome: Brief episodes (seconds to minutes) triggered by head movements or position changes 2, 3
• Spontaneous Episodic Vestibular Syndrome: Episodes occurring without specific triggers 1, 2
• Chronic Vestibular Syndrome: Persistent symptoms lasting months 2

Critical History Elements to Obtain

Duration and onset are the most important historical features, not whether the patient describes "spinning" versus "lightheadedness" 1, 2:

• Seconds to minutes with head movement triggers: Strongly suggests BPPV 2, 3
• Days to weeks of constant symptoms: Indicates AVS, requiring differentiation between peripheral (vestibular neuritis) and central (stroke) causes 1, 2
• Associated headache, photophobia, phonophobia: Suggests vestibular migraine 2
• Hearing loss, tinnitus, or aural fullness: Suggests Ménière's disease 1, 2
• Neurological symptoms (diplopia, dysarthria, numbness, weakness): Red flags for central causes requiring urgent evaluation 1, 2

Essential Physical Examination Maneuvers

Perform these specific bedside tests based on the timing pattern 1, 2, 3:

For Triggered Episodic Dizziness (Suspected BPPV):

• Dix-Hallpike maneuver: Look for characteristic torsional, upbeating nystagmus for posterior canal BPPV 2, 3
• Supine roll test: Assesses for horizontal canal BPPV 1, 2

For Acute Vestibular Syndrome:

• HINTS examination (Head Impulse, Nystagmus, Test of Skew): When performed by trained practitioners, this is more sensitive than early MRI for detecting posterior circulation stroke (100% vs 46% sensitivity) 2, 3
• Observe for spontaneous nystagmus in all patients 1

Critical pitfall: 75-80% of patients with acute vestibular syndrome from posterior circulation infarct have NO focal neurologic deficits, so a normal neurologic exam does NOT exclude stroke 2

Imaging Decisions: When to Order and When to Avoid

NO imaging indicated for 2, 3:

• Brief episodic vertigo with typical BPPV features and positive Dix-Hallpike test
• Acute persistent vertigo with normal neurologic exam AND HINTS examination consistent with peripheral vertigo (when performed by trained examiner)

MRI brain (with diffusion-weighted imaging) IS indicated for 1, 2:

• Acute persistent vertigo with abnormal neurologic examination
• HINTS examination suggesting central cause
• High vascular risk patients with acute vestibular syndrome
• Focal neurological deficits, sudden hearing loss, inability to stand or walk
• Downbeating nystagmus or other central nystagmus patterns
• New severe headache (requires immediate imaging and neurologic consultation)

Critical pitfall: CT head has low detection rate for isolated dizziness and misses many posterior circulation infarcts; MRI is strongly preferred when stroke is suspected 2

Avoid overuse pitfall: Routine imaging for isolated dizziness has low yield and most findings are incidental 2

Immediate Treatment Based on Diagnosis

For BPPV (most common cause):

• Canalith repositioning procedures (Epley maneuver) are first-line treatment with 90-98% success rate 2, 3
• No imaging or medication needed for typical cases 2, 3

For Vestibular Neuritis (peripheral AVS):

• Vestibular rehabilitation is helpful 4
• Pharmacologic intervention is limited as it affects central nervous system compensation 4

For suspected stroke or central causes:

• Urgent neurologic consultation and MRI 2
• Do NOT delay evaluation with symptomatic medications 2

Patient Education and Safety Counseling

Educate patients on 5, 3:

• Fall risk: BPPV and vestibular disorders significantly increase fall risk, particularly in elderly patients 5
• Recurrence rates: BPPV recurs in 10-18% at 1 year and up to 36% long-term 5
• When to return: New severe headache, inability to walk, neurological symptoms, or failure to respond to appropriate treatment 2
• Safety modifications: Adjust daily routines to minimize impact during symptomatic periods 5

Common Pitfalls to Avoid

• Do NOT rely on patient descriptions of "spinning" versus "lightheadedness"—focus on timing and triggers instead 1, 2
• Do NOT assume normal neurologic exam excludes stroke in acute vestibular syndrome 2
• Do NOT perform HINTS examination if not properly trained, as results are unreliable when performed by non-experts 2
• Do NOT order CT instead of MRI when stroke is suspected 2
• Do NOT fail to perform appropriate bedside tests (Dix-Hallpike, HINTS) before ordering imaging 1, 2