What is the step-by-step approach to diagnosing and treating a case of vertigo with different diagnoses?

Step-by-Step Approach to Vertigo

Focus your initial assessment on timing and triggers of symptoms rather than the patient's subjective description of "dizziness" or "spinning," as this timing-and-trigger framework is the most diagnostically valuable approach. 1, 2

Step 1: Classify by Timing and Triggers

Categorize the presentation into one of four distinct vestibular syndromes 1, 2:

Triggered Episodic Vestibular Syndrome

• Brief episodes (<1 minute) provoked by specific head position changes 1, 2
• Most commonly BPPV 1
• Perform Dix-Hallpike maneuver immediately 3

Spontaneous Episodic Vestibular Syndrome

• Episodes lasting minutes to hours without positional triggers 1
• Consider Ménière's disease (with hearing loss, tinnitus, aural fullness) 1, 3
• Consider vestibular migraine (with headache, photophobia, phonophobia) 2, 3

Acute Vestibular Syndrome

• Continuous vertigo lasting days to weeks with nausea, vomiting, intolerance to head motion 1
• Differential includes vestibular neuritis, labyrinthitis, or posterior circulation stroke 1
• Perform HINTS examination immediately—it has 100% sensitivity for stroke when done by trained practitioners versus only 46% for early MRI 2, 4

Chronic Vestibular Syndrome

• Dizziness lasting weeks to months or longer 1
• Review medications (antihypertensives, sedatives, anticonvulsants, psychotropics) 2
• Screen for anxiety, panic disorder, depression 2

Step 2: Distinguish Peripheral from Central Causes

Peripheral Vertigo Features 3

• Horizontal nystagmus with rotatory (torsional) component 3
• Unidirectional nystagmus 3
• Suppressed by visual fixation 3
• Fatigable with repeated testing 3

Central Vertigo Features (Red Flags) 3

• Pure vertical nystagmus without torsional component 3
• Direction-changing nystagmus without head position changes 3
• Not suppressed by visual fixation 3
• Focal neurological deficits 2
• Sudden hearing loss 2
• Inability to stand or walk 2, 4
• New severe headache 2
• Downbeating nystagmus 2

Step 3: Perform Targeted Physical Examination

For Triggered Episodic Vertigo (Suspected BPPV)

Dix-Hallpike Maneuver 3:

• Bring patient from upright to supine with head turned 45 degrees to one side and neck extended 20 degrees 3
• Positive test criteria: latency period 5-20 seconds, provoked vertigo and nystagmus that increase then resolve within 60 seconds, rotatory nystagmus beating toward affected ear 3
• If positive with typical features, no imaging or vestibular testing is needed 2, 3

For Acute Vestibular Syndrome

HINTS Examination (Head Impulse, Nystagmus, Test of Skew) 2:

• Critical caveat: HINTS is only reliable when performed by trained practitioners; non-expert results are unreliable 2
• If HINTS suggests central cause or you are not trained in HINTS, proceed directly to MRI 2

Supine Roll Test for Lateral Canal BPPV 1

• Geotropic form: side with strongest nystagmus is affected ear 1
• Apogeotropic form: side opposite strongest nystagmus is affected ear 1

Step 4: Determine Need for Imaging

No Imaging Indicated 2

• Brief episodic vertigo with typical BPPV features and positive Dix-Hallpike 2
• Acute persistent vertigo with normal neurologic exam AND HINTS consistent with peripheral vertigo by trained examiner 2

MRI Brain Without Contrast Indicated 2, 4

• Abnormal neurologic examination 2
• HINTS examination suggesting central cause 2
• High vascular risk patients with acute vestibular syndrome 2, 4
• Unilateral tinnitus or pulsatile tinnitus 2
• Asymmetric hearing loss 2
• Progressive symptoms suggesting mass lesion 2

CT Head Has Very Low Yield 2

• CT has <1% diagnostic yield for isolated dizziness and only 20-40% sensitivity for posterior circulation infarcts 2
• May be appropriate before MRI in acute settings when stroke suspected, but should not replace MRI 2

Step 5: Differential Diagnosis by Category

Triggered Episodic (Positional)

• BPPV (42% of general practice vertigo cases) 1, 3
• Postural hypotension 1
• Perilymph fistula (pressure-triggered, may have fluctuating hearing loss) 1
• Superior canal dehiscence syndrome (pressure-triggered, not position-triggered; may have conductive hearing loss) 1
• Central paroxysmal positional vertigo 1

Spontaneous Episodic

• Vestibular migraine (headache, photophobia, phonophobia) 1, 2
• Ménière's disease (10% of cases; fluctuating hearing loss, tinnitus, aural fullness) 1, 3
• Posterior circulation TIA 1
• Medication side effects 1
• Anxiety or panic disorder 1

Acute Vestibular Syndrome

• Vestibular neuritis (41% of cases; no hearing loss) 1, 3
• Labyrinthitis (with hearing loss) 1
• Posterior circulation stroke (25% of acute vestibular syndrome; 75% in high vascular risk cohorts) 4
• Demyelinating diseases 1
• Posttraumatic vertigo 1

Chronic Vestibular Syndrome

• Medication side effects (leading cause) 2
• Anxiety or panic disorder 1, 2
• Posttraumatic vertigo 1, 2
• Posterior fossa mass lesions 1
• Cervicogenic vertigo 1

Step 6: Treatment Based on Diagnosis

BPPV

Canalith repositioning procedures (Epley maneuver) are first-line treatment 2

• No imaging or medication needed for typical cases 2
• If no response after 2-3 attempts, evaluate for central pathology 3

Vestibular Neuritis/Labyrinthitis

• Vestibular suppressant medications (meclizine is FDA-approved for vertigo associated with vestibular system diseases) 5
• Vestibular rehabilitation exercises 6, 7

Ménière's Disease

• Salt restriction 2, 6
• Diuretics 2, 6
• Intratympanic treatments in refractory cases 2

Vestibular Migraine

• Migraine prophylaxis 2
• Lifestyle modifications 2

Critical Pitfalls to Avoid

Assuming normal neurologic exam excludes stroke: 75-80% of patients with acute vestibular syndrome from posterior circulation infarct have no focal neurologic deficits on standard examination 2, 4

Relying on patient's description of "spinning" versus "lightheadedness": This distinction has limited clinical usefulness; focus on timing and triggers instead 2, 6

Overreliance on CT imaging: CT misses many posterior circulation infarcts and should not be used instead of MRI when stroke is suspected 2

Performing HINTS examination without proper training: Results are unreliable when performed by non-experts 2

Ordering routine imaging or vestibular testing for straightforward BPPV: This is unnecessary, delays treatment, and adds cost 2, 3

Missing medication-induced vertigo: Always review medications, as this is one of the most common and reversible causes of chronic dizziness 2