What are the recommended evaluation and treatment options for frequent dizzy spells throughout the day?

Evaluation and Management of Frequent Dizzy Spells Throughout the Day

For dizzy spells occurring throughout the day, you must first determine the timing and triggers of episodes to classify the syndrome, then perform targeted physical examination including the Dix-Hallpike maneuver and HINTS examination to distinguish benign peripheral causes from dangerous central causes like stroke, avoiding reliance on imaging or medications until the diagnosis is clear. 1, 2

Initial Diagnostic Approach: Timing and Triggers Over Symptom Quality

The traditional approach of asking patients to describe their dizziness as "spinning" versus "lightheadedness" is unreliable and should be abandoned. 2 Instead, focus your history on:

• Duration of each episode: Seconds suggest BPPV, minutes to hours suggest Ménière's disease or vestibular migraine, days to weeks suggest vestibular neuritis or stroke 1, 2
• Triggers: Position changes point to BPPV, no trigger suggests vestibular migraine or Ménière's disease 1, 2
• Pattern: Episodic throughout the day versus continuous symptoms 3, 1

This timing-and-triggers approach classifies patients into four vestibular syndromes that guide your differential diagnosis and examination 3, 1:

1. Triggered episodic vestibular syndrome (brief episodes with position changes): BPPV, postural hypotension 3
2. Spontaneous episodic vestibular syndrome (episodes without triggers, minutes to hours): Vestibular migraine, Ménière's disease 3
3. Acute vestibular syndrome (continuous symptoms for days): Vestibular neuritis, stroke 3
4. Chronic vestibular syndrome (persistent symptoms for weeks to months): Anxiety, medication side effects, posttraumatic vertigo 3

Critical Associated Symptoms to Elicit

• Hearing loss, tinnitus, or aural fullness: Suggests Ménière's disease (episodic attacks with all three symptoms) 3
• Headache, photophobia, phonophobia: Suggests vestibular migraine 3, 2
• Focal neurological symptoms: Dysarthria, dysphagia, sensory/motor loss, diplopia—these are red flags for stroke 3, 4

Critical pitfall: Up to 75-80% of patients with posterior circulation stroke present with isolated dizziness without focal neurological deficits, so their absence does not exclude stroke. 4, 2

Essential Physical Examination Components

For Triggered Episodic Symptoms (Position-Related)

Perform the Dix-Hallpike maneuver to diagnose BPPV—this is more important than any imaging study. 3, 1 A positive test shows:

• Brief latency (few seconds) before nystagmus onset 3
• Torsional nystagmus with upbeating component 3
• Symptoms that fatigue with repeated testing 3

Warning signs of central pathology on Dix-Hallpike include 3, 4:

• Downbeating nystagmus without torsional component
• Direction-changing nystagmus without head position changes
• Nystagmus that doesn't fatigue or resolve
• Inability to perform the maneuver due to severe symptoms

For Acute Continuous Symptoms

Perform the HINTS examination (Head Impulse, Nystagmus, Test of Skew) if the patient has continuous vertigo—this is more sensitive than early MRI for detecting stroke (100% vs 46% sensitivity when performed by trained practitioners). 4, 2

• Abnormal head impulse test (corrective saccade): Suggests peripheral cause 4
• Direction-changing nystagmus: Suggests central cause (stroke) 4
• Vertical skew deviation: Suggests central cause (stroke) 4

Critical limitation: HINTS examination is unreliable when performed by non-experts, so if you're not trained in this technique, maintain high suspicion for stroke and obtain MRI. 2

When to Order Imaging

Do NOT order imaging 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)
• Routine isolated dizziness (diagnostic yield <1% for CT, only 4% for MRI) 2

Order MRI brain without contrast for: 4, 2

• Abnormal neurologic examination
• HINTS examination suggesting central cause
• High vascular risk patients with acute vestibular syndrome
• Unilateral tinnitus or asymmetric hearing loss
• Failure to respond to appropriate vestibular treatments
• New severe headache accompanying dizziness

Never rely on CT for suspected stroke—CT misses the majority of posterior circulation infarcts that cause dizziness. 4, 2

Treatment Based on Diagnosis

BPPV (Most Common Cause)

Perform canalith repositioning procedure (Epley maneuver) as first-line treatment—no medications or imaging needed for typical cases. 3, 2 This has high success rates but recurrence occurs in 10-18% at one year and up to 36% long-term. 3

Counsel patients about: 3

• Fall risk, particularly in elderly (53% fall at least once per year with BPPV)
• Recurrence likelihood and when to return for repeat treatment
• Home safety assessment for elderly patients

Vestibular Migraine

Treat with migraine prophylaxis and lifestyle modifications. 2 Diagnostic criteria require ≥5 episodes of vestibular symptoms lasting 5 minutes to 72 hours, history of migraine, and migraine features during ≥50% of dizzy episodes. 3

Ménière's Disease

Manage with salt restriction and diuretics as first-line treatment. 2 Diagnosis requires episodic vertigo with fluctuating hearing loss, tinnitus, and aural fullness. 3

Vestibular Neuritis

Treat with vestibular suppressant medications (meclizine 25-100 mg daily in divided doses) for symptom relief and vestibular rehabilitation for recovery. 5 Important: Meclizine causes drowsiness and should not be used long-term or for chronic dizziness. 5

Absolute Red Flags Requiring Urgent Evaluation

• Focal neurological deficits (even subtle) 4, 1
• Sudden hearing loss 1, 2
• Inability to stand or walk 1, 2
• New severe headache 2
• Downbeating nystagmus or other central nystagmus patterns 3, 2
• Failure to respond to appropriate vestibular treatments 3, 2

Assessment for Fall Risk and Modifying Factors

Evaluate all patients for factors that modify management: 3, 4

• Impaired mobility or balance
• CNS disorders
• Lack of home support
• Age >65 (12-fold increased fall risk) 4

Elderly and frail patients require counseling about home safety, activity restrictions, and potential need for supervision until symptoms resolve. 3

Common Pitfalls to Avoid

• Don't rely on patient descriptions of "spinning" versus "lightheadedness"—focus on timing and triggers instead 2
• Don't assume normal neurologic exam excludes stroke—most posterior circulation strokes present without focal deficits 4, 2
• Don't order routine imaging for isolated dizziness—yield is extremely low and most findings are incidental 2
• Don't use CT instead of MRI when stroke is suspected—CT frequently misses posterior circulation strokes 4, 2
• Don't skip the Dix-Hallpike maneuver in patients with positional symptoms—this is your most important diagnostic tool 3, 1