What is the approach to managing a patient presenting with dizziness?

Approach to Managing a Patient Presenting with Dizziness

Categorize dizziness by timing and triggers—not by the patient's vague description of symptoms—to determine the specific vestibular syndrome and guide targeted physical examination and management. 1, 2

Initial Categorization: The Timing and Triggers Framework

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

1. Acute Vestibular Syndrome (AVS)

• Acute persistent dizziness lasting days to weeks with constant symptoms 1, 2
• Key examination: HINTS (Head Impulse, Nystagmus, Test of Skew) to differentiate peripheral (vestibular neuritis) from central causes (stroke) 1, 2
• HINTS has 100% sensitivity for posterior circulation stroke when performed by trained practitioners, superior to early MRI (46% sensitivity) 2
• Critical pitfall: 75-80% of patients with posterior circulation stroke have NO focal neurologic deficits, so a normal neurologic exam does NOT exclude stroke 2, 3

2. Triggered Episodic Vestibular Syndrome

• Brief episodes lasting seconds to minutes triggered by specific head movements 1, 2
• Perform Dix-Hallpike maneuver and supine roll test to diagnose BPPV 1, 2
• If positive for BPPV: treat immediately with canalith repositioning procedures (Epley maneuver)—no imaging or medication needed 2

3. Spontaneous Episodic Vestibular Syndrome

• Episodes lasting minutes to hours without positional triggers 1, 2
• Assess for associated symptoms:
  • Hearing loss, tinnitus, aural fullness → Ménière's disease (episodes 20 minutes to 12 hours) 4, 2, 3
  • Headache, photophobia, phonophobia → Vestibular migraine (episodes 5 minutes to 72 hours, ≥5 episodes with migraine features in ≥50%) 2, 3

4. Chronic Vestibular Syndrome

• Persistent symptoms lasting weeks to months 1, 2
• Requires comprehensive vestibular assessment and consideration of central causes 2

Essential History Elements

Do NOT rely on patient descriptions of "spinning" versus "lightheadedness"—these are unreliable and do not distinguish benign from dangerous causes 2, 3. Instead, focus on:

• Duration and onset: Seconds? Minutes? Hours? Days? 1, 2
• Triggers: Head position changes? Spontaneous? 1, 2
• Associated symptoms: Hearing loss, tinnitus, headache, neurologic symptoms (diplopia, dysarthria, numbness, weakness) 4, 1, 3

Physical Examination Protocol

For All Patients:

• Observe for spontaneous nystagmus at rest 1
• Complete neurologic examination including cranial nerves, cerebellar testing, gait assessment 1, 2

For Suspected BPPV (Triggered Episodes):

• Dix-Hallpike maneuver for posterior canal BPPV 4, 1
• Supine roll test for horizontal canal BPPV 1

For AVS (Acute Persistent Dizziness):

• HINTS examination (only if trained—unreliable when performed by non-experts) 2
• Central features suggesting stroke: downbeating nystagmus without torsional component, direction-changing nystagmus without head position change, gaze-evoked nystagmus 4

Imaging Decisions: When to Order and When to Avoid

NO imaging indicated for: 2

• Brief episodic vertigo with typical BPPV features on Dix-Hallpike
• Acute persistent vertigo with normal neurologic exam AND HINTS consistent with peripheral vertigo (by trained examiner)

MRI brain (without contrast, with diffusion-weighted imaging) indicated for: 1, 2

• Abnormal neurologic examination
• HINTS examination suggesting central cause
• High vascular risk patients with acute vestibular syndrome
• Unilateral tinnitus or pulsatile tinnitus
• Asymmetric hearing loss
• Focal neurological deficits

CT has limited utility: 2

• Low detection rate for isolated dizziness
• Misses many posterior circulation infarcts
• May be used acutely before MRI availability, but should not replace MRI when stroke suspected

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

Red Flags Requiring Urgent Evaluation

These mandate immediate imaging and neurologic consultation 1, 2, 3:

• Focal neurological deficits (diplopia, dysarthria, numbness, weakness)
• Sudden hearing loss
• Inability to stand or walk
• Downbeating nystagmus or other central nystagmus patterns
• New severe headache
• Failure to respond to appropriate vestibular treatments

Treatment Based on Diagnosis

BPPV:

• Canalith repositioning procedures (Epley maneuver) as first-line treatment 2
• Educate about 10-18% recurrence rate at 1 year, up to 36% long-term 4
• Assess fall risk, especially in elderly (9% of geriatric patients have undiagnosed BPPV, 75% had fallen within 3 months) 4

Ménière's Disease:

• Salt restriction and diuretics 2
• Consider intratympanic treatments for refractory cases 2

Vestibular Migraine:

• Migraine prophylaxis and lifestyle modifications 2, 3

Vestibular Neuritis (AVS with peripheral HINTS):

• Vestibular rehabilitation 5
• Short-term vestibular suppressants only during acute phase 5

Special Consideration: Dizziness in Heart Failure Patients

If patient is on guideline-directed medical therapy (GDMT) for heart failure with reduced ejection fraction 4:

• If stable on optimal GDMT: Dizziness is unlikely related to HF therapy—look for other etiologies (BPPV, vestibular disorders, valvular disease) 4
• If GDMT recently initiated or up-titrated: May be medication-related; assess congestion status and consider diuretic reduction if euvolemic 4
• Educate patients: Transient dizziness upon standing is a side effect of life-prolonging HF drugs and does not necessitate dose reduction 4

Common Pitfalls to Avoid

1. Relying on symptom quality ("spinning" vs "lightheadedness") rather than timing and triggers 2, 3
2. Assuming normal neurologic exam excludes stroke in acute vestibular syndrome 2, 3
3. Overuse of imaging for clear peripheral causes with appropriate bedside testing 1, 2
4. Failing to perform Dix-Hallpike when BPPV is suspected 1, 2
5. Using CT instead of MRI when stroke is suspected 2
6. Not assessing fall risk in elderly patients with vestibular disorders 4