How do I approach a patient with vertigo in terms of history taking and physical examination?

Approaching a Patient with Vertigo: History and Physical Examination

Define True Vertigo First

Your first critical task is to determine whether the patient is experiencing true vertigo (a sensation of spinning or rotational movement) versus vague dizziness, lightheadedness, or presyncope. 1, 2 This distinction fundamentally changes your diagnostic approach and management.

• A confident description of spinning is specific for inner ear dysfunction 1
• Feeling like one might faint or pass out suggests presyncope, NOT vertigo 1
• Feeling unsteady or off-balance without spinning represents dizziness rather than true vertigo 1
• Elderly patients often struggle to articulate symptoms clearly and may present with atypical "vestibular disturbance" rather than frank spinning sensations 1

Critical pitfall to avoid: Do not rely solely on the patient's vague description of "dizziness"—focus instead on timing, triggers, and associated symptoms to clarify the exact nature of their complaint. 2

Essential History Questions

Duration of Episodes (Most Important Discriminator)

The precise duration of vertigo episodes is the single most important historical feature that distinguishes most causes. 1, 2

• Seconds only (<1 minute): Strongly suggests BPPV (benign paroxysmal positional vertigo) 3, 1
• Minutes duration: Consider stroke/TIA or vestibular migraine 1
• Hours to days: Think Menière's disease or vestibular neuronitis 4, 5
• Constant/persistent (days to weeks): Acute vestibular syndrome—requires urgent evaluation for stroke 2, 6

Triggering Factors

• Positional triggers: Ask specifically about rolling over in bed, looking upward, or bending forward—these strongly suggest BPPV 3, 1
• Spontaneous onset: No clear trigger suggests vestibular neuronitis, Menière's disease, or central causes 4, 5

Associated Symptoms

• Hearing loss, tinnitus, or aural fullness: Suggests Menière's disease 2, 4
• Headache with photophobia/phonophobia: Consider vestibular migraine 2
• History of migraine: Highly relevant—34% of BPPV patients have migraine history 1
• Neurologic symptoms: Headache, diplopia, dysarthria, weakness, or numbness are red flags for central causes 6, 4, 7

Medication Review

• Review all medications, particularly antihypertensives, sedatives, anticonvulsants, and psychotropic drugs—these are leading causes of chronic vestibular syndrome 2

Physical Examination: Systematic Approach

The Dix-Hallpike Maneuver (Essential for BPPV Diagnosis)

Perform the Dix-Hallpike maneuver in every patient with positional vertigo—this is the gold standard for diagnosing BPPV, the most common cause of vertigo. 3

Diagnostic criteria for positive Dix-Hallpike: 3

• Latency period of 5-20 seconds (up to 1 minute) between completing the maneuver and onset of vertigo/nystagmus
• Provoked vertigo and nystagmus increase then resolve within 60 seconds from onset
• Rotatory nystagmus beating toward the affected (downward) ear

Important note: Up to one-third of patients with atypical histories will still show positive Dix-Hallpike testing, confirming BPPV 3

HINTS Examination (For Acute Vestibular Syndrome)

If the patient has acute, persistent vertigo lasting hours to days, perform the HINTS examination (Head Impulse, Nystagmus, Test of Skew)—this has 100% sensitivity for detecting stroke when performed by trained practitioners, superior to early MRI (46% sensitivity). 1, 2, 6, 8

Components of HINTS: 8

1. Head Impulse Test (HIT):

   • Normal (abnormal test) = corrective saccade present = peripheral cause (sensitivity 76.8%, specificity 89.1%) 8
   • Abnormal (normal test) = no corrective saccade = central cause/stroke 6, 8

2. Nystagmus assessment:

   • Central patterns (red flags): Downbeating nystagmus, direction-changing nystagmus without head position changes, gaze-holding nystagmus, or pure vertical nystagmus 1, 6, 8
   • Peripheral pattern: Unidirectional horizontal nystagmus that lessens with visual fixation 4, 8

3. Test of Skew:

   • Skew deviation (vertical misalignment on alternate cover test) suggests central cause (sensitivity 23.7%, specificity 97.6%) 8

HINTS+ adds hearing assessment: Acute hearing loss in addition to abnormal HINTS increases sensitivity to 99% for stroke 8

Critical caveat: HINTS examination is less reliable when performed by non-experts—if you are not trained in this technique, obtain urgent neuroimaging for acute vestibular syndrome. 2

Comprehensive Neurologic Examination

Perform a focused posterior circulation assessment in all patients with vertigo: 1, 6

• Cranial nerve testing: Look for ophthalmoplegia, facial weakness, or other focal deficits 7
• Cerebellar testing: Finger-to-nose, heel-to-shin, rapid alternating movements 7, 8
• Truncal/gait ataxia: Inability to stand or walk is a major red flag (sensitivity 69.7%, specificity 83.7% for central cause) 8
• Limb weakness/hemiparesis: High specificity (98.5%) but low sensitivity (11.4%) for central causes 8
• Dysmetria: Sensitivity 24.6%, specificity 97.8% for central etiology 8

Critical pitfall: Up to 75-80% of patients with stroke-related acute vestibular syndrome have NO focal neurologic deficits—do not assume a normal neurologic exam excludes stroke. 2, 6, 8

Otologic Examination

• Examine tympanic membranes for infection, effusion, or perforation 4, 7
• Assess hearing with whisper test or finger rub 9
• Check for spontaneous nystagmus (sensitivity 52.3%, specificity 42% for central causes) 8

Gait and Balance Assessment

• Observe the patient walking—assess for ataxia, veering, or inability to ambulate 7, 8
• Romberg test and tandem gait testing 7
• Falls risk screening, particularly in elderly patients (12-fold increased fall risk) 6

Red Flags Requiring Urgent Evaluation

Any of the following mandate immediate neuroimaging (preferably MRI) and neurologic consultation: 3, 2, 6

• Focal neurological deficits (even subtle)
• Sudden hearing loss
• Inability to stand or walk
• New severe headache
• Downbeating nystagmus or other central nystagmus patterns
• Failure to respond to appropriate vestibular treatments after 2-3 attempts
• High vascular risk factors (age >50, hypertension, diabetes, prior stroke) with acute vestibular syndrome

When NOT to Order Additional Testing

Do not order neuroimaging or vestibular testing in patients who meet diagnostic criteria for BPPV with a positive Dix-Hallpike test and no additional concerning features. 3 The diagnosis is clinical, and imaging does not improve diagnostic accuracy in typical BPPV cases. 3

Do not order comprehensive vestibular testing for straightforward BPPV—it is unnecessary and delays treatment. 3 Vestibular testing may be appropriate only if the clinical presentation is atypical, Dix-Hallpike findings are equivocal, or additional symptoms suggest concurrent CNS or otologic disorders. 3

Common Pitfalls Summary

• Never rely solely on CT imaging for suspected stroke—CT frequently misses posterior circulation strokes (sensitivity only 20-40%) 2, 6
• Do not assume absence of focal deficits rules out stroke—most stroke patients with acute vestibular syndrome have no focal signs 2, 6
• Do not skip the Dix-Hallpike maneuver—failure to perform appropriate positional testing is a major diagnostic error 2
• Do not order routine imaging for typical BPPV—it adds cost without improving outcomes 3