What is the appropriate workup for a patient with chronic dizziness (lasting over 1 year)?

Workup of Chronic Dizziness (>1 Year Duration)

For chronic dizziness lasting over a year, you should systematically evaluate for the most common causes in the chronic vestibular syndrome category—anxiety/panic disorder, medication side effects, posttraumatic vertigo, and posterior fossa mass lesions—while ruling out red flags that require urgent neuroimaging. 1

Initial History: Focus on Timing and Triggers

The American Academy of Otolaryngology-Head and Neck Surgery emphasizes that timing and triggers are more diagnostically valuable than the patient's subjective description of their dizziness (e.g., "spinning" vs "lightheadedness"). 1, 2

For chronic dizziness (lasting weeks to months or longer), specifically assess:

• Medication review: This is a leading cause of chronic vestibular syndrome. Review all medications, particularly antihypertensives, sedatives, anticonvulsants, and psychotropic drugs. 1

• Psychiatric symptoms: Screen for anxiety, panic disorder, and depression, as these are common causes of chronic dizziness. 1

• Trauma history: Ask about prior head trauma or whiplash injury, as posttraumatic vertigo can persist chronically. 1

• Associated symptoms:

  • Hearing loss, tinnitus, or aural fullness suggest Ménière's disease (though typically episodic, not continuous). 1
  • Headache with photophobia/phonophobia suggests vestibular migraine. 2
  • Progressive neurologic symptoms suggest posterior fossa pathology. 1

Physical Examination: Identify Red Flags

Perform a complete otologic and neurologic examination focusing on:

• Nystagmus assessment: Downbeating nystagmus or other central patterns mandate urgent evaluation. 2

• Neurologic examination: Look for focal deficits, cerebellar signs, or cranial nerve abnormalities. 2, 3

• Positional testing: Perform Dix-Hallpike and supine roll test even in chronic cases to rule out persistent BPPV. 2, 3

• Gait and balance testing: Inability to stand or walk is a red flag requiring urgent workup. 2

Diagnostic Testing Strategy

Imaging is NOT routinely indicated for chronic dizziness unless red flags are present. 2

When to Order MRI Brain (Without Contrast):

• Focal neurological deficits on examination 2
• Unilateral or pulsatile tinnitus 2
• Asymmetric hearing loss 2
• Failure to respond to appropriate vestibular treatments 2
• Progressive symptoms suggesting mass lesion 1
• Atypical presentation or central nystagmus patterns 2

Important: CT head has extremely poor diagnostic yield (<1%) for isolated dizziness and misses most posterior circulation pathology—always use MRI when imaging is indicated. 2

Audiologic Testing:

• Obtain comprehensive audiometry for patients with unilateral tinnitus, persistent symptoms, or associated hearing difficulties. 2

Laboratory Testing:

• Consider basic metabolic panel, CBC, and thyroid function only if specific systemic causes are suspected (e.g., anemia, electrolyte abnormalities, thyroid dysfunction). 3
• Routine laboratory testing has low diagnostic yield in isolated chronic dizziness. 4

Common Pitfalls to Avoid

• Do not assume normal neurologic exam excludes central pathology: 75-80% of patients with posterior circulation stroke have no focal neurologic deficits. 2

• Do not rely on patient's description alone: The specific words patients use ("dizzy," "spinning," "lightheaded") are unreliable—focus on timing, triggers, and associated symptoms instead. 1, 2

• Do not order routine imaging: Most findings will be incidental and not causative of symptoms. 2

• Do not forget medication review: This is one of the most common and reversible causes of chronic dizziness. 1

Management Approach

Once red flags are excluded:

• Treat identified causes: Adjust or discontinue offending medications, treat psychiatric comorbidities, manage vestibular migraine with prophylaxis. 2

• Vestibular rehabilitation: This is beneficial for most peripheral and many central causes of chronic dizziness. 5

• Avoid chronic vestibular suppressants: Medications like meclizine impair central compensation and should not be used long-term. 5

• Consider referral: If diagnosis remains unclear after initial workup or symptoms persist despite treatment, refer to otolaryngology or neurology for specialized vestibular testing. 3

In approximately 20% of chronic dizziness cases, a definitive diagnosis may not be reached despite thorough evaluation. 4 In these cases, focus on symptomatic management with vestibular rehabilitation and addressing contributing factors like anxiety or medication effects.