What is the initial evaluation and management approach for a patient presenting with dizziness?

Initial Evaluation and Management of Dizziness

Focus on timing and triggers rather than the patient's subjective description of "spinning" or "lightheadedness" to categorize dizziness into specific vestibular syndromes, which will guide your diagnostic approach and avoid unnecessary testing. 1, 2

Categorize by Timing and Triggers

The modern approach divides dizziness into four key clinical syndromes based on duration and precipitants 1, 2, 3:

1. Triggered Episodic Vestibular Syndrome (Brief Episodes)

• Duration: Seconds to minutes, triggered by head movements 1
• Most likely diagnosis: Benign Paroxysmal Positional Vertigo (BPPV) 1, 2
• Action: Perform Dix-Hallpike maneuver and supine roll test immediately 1, 2, 3
• Management: If positive, treat with canalith repositioning procedures (Epley maneuver) 1
• No imaging or medications needed for typical BPPV 1

2. Acute Vestibular Syndrome (Persistent Symptoms)

• Duration: Days to weeks of constant symptoms 1, 3
• Differential: Vestibular neuritis vs. posterior circulation stroke 1, 4
• Critical action: Perform HINTS examination (Head Impulse, Nystagmus, Test of Skew) if you are trained 1, 2
  • HINTS has 100% sensitivity for stroke when performed by trained practitioners (vs. 46% for early MRI) 1
  • If HINTS suggests peripheral cause AND you are trained in the exam AND neurologic exam is normal: no imaging needed 1
  • If HINTS suggests central cause OR you are not trained OR patient has vascular risk factors: obtain MRI brain without contrast immediately 1, 4

3. Spontaneous Episodic Vestibular Syndrome

• Duration: Minutes to hours, no positional trigger 2, 3
• Key differentials: Vestibular migraine vs. transient ischemic attack vs. Ménière's disease 1, 2
• Look for: Headache, photophobia, phonophobia (suggests vestibular migraine) 1
• Look for: Hearing loss, tinnitus, aural fullness (suggests Ménière's disease) 1, 2

4. Chronic Vestibular Syndrome

• Duration: Persistent symptoms for weeks to months 1, 2
• First steps: Medication review (antihypertensives, sedatives, anticonvulsants, psychotropics are leading causes) 1
• Screen for: Anxiety, panic disorder, depression 1

Essential History Elements

Obtain these specific details 1, 2:

• Timing: Exact duration of episodes (seconds vs. minutes vs. hours vs. days)
• Triggers: Head position changes, standing up, specific movements
• Associated symptoms:
  • Hearing loss or tinnitus (suggests Ménière's or acoustic neuroma) 1, 2
  • Headache, diplopia, dysarthria, numbness, weakness (suggests central cause) 2, 4
  • Loss of consciousness (never occurs with peripheral vestibular disorders—indicates cardiac or neurologic cause) 4

Physical Examination Protocol

For All Patients:

• Observe for spontaneous nystagmus 2
• Complete neurologic examination (though 75-80% of posterior circulation strokes have NO focal deficits) 4

For Suspected BPPV:

• Dix-Hallpike maneuver: Look for latency of 5-20 seconds, rotatory nystagmus toward affected ear, symptoms that resolve within 60 seconds 1, 2
• Supine roll test: For horizontal canal BPPV 2

For Acute Vestibular Syndrome (if trained):

• HINTS examination: Normal head impulse test in acute vertigo suggests central cause 4

Imaging Decisions

Do NOT order imaging for:

• Typical BPPV with positive Dix-Hallpike and no red flags 1, 2
• Acute persistent vertigo with normal neurologic exam AND reassuring HINTS by trained examiner AND no vascular risk factors 1

Order MRI brain without contrast for:

• Abnormal neurologic examination 1
• HINTS examination suggesting central cause 1, 4
• High vascular risk patients with acute vestibular syndrome 1, 4
• Any red flag symptoms (see below) 1, 4

Critical imaging pitfall:

• CT head has only 20-40% sensitivity for posterior circulation stroke and misses most causative pathology in dizziness 4
• MRI with diffusion-weighted imaging is the appropriate study 4
• CT may be used initially in acute settings before MRI, but cannot exclude stroke 5, 4

Red Flags Requiring Urgent Evaluation

These mandate immediate imaging and neurologic consultation 1, 4:

• Focal neurological deficits: Diplopia, dysarthria, facial numbness, limb weakness, sensory changes 4
• Inability to stand or walk independently 1, 4
• New severe headache 1, 4
• Sudden unilateral hearing loss 4
• Downbeating nystagmus or other central nystagmus patterns 1, 4
• Normal head impulse test in acute vertigo with nystagmus (suggests central cause) 4
• Unilateral or pulsatile tinnitus 4
• Failure to respond to appropriate vestibular treatments 1, 4

Critical Pitfalls to Avoid

• Do not rely on patient descriptions of "spinning" vs. "lightheadedness"—these are unreliable and do not distinguish benign from dangerous causes 1, 4, 3
• Do not assume normal neurologic exam excludes stroke—75-80% of posterior circulation strokes present with isolated dizziness and no focal deficits 4
• Do not order routine imaging for isolated dizziness with typical peripheral features—diagnostic yield is <1% for CT and most findings are incidental 1, 4
• Do not use CT instead of MRI when stroke is suspected—CT misses most posterior circulation infarcts 4
• Do not skip bedside testing—Dix-Hallpike and HINTS provide more diagnostic value than imaging in most cases 4
• Do not order vestibular testing for straightforward BPPV—it delays treatment unnecessarily 1

Special Considerations

BPPV Recurrence:

• Recurrence rates: 10-18% at 1 year, up to 36% long-term 5
• Counsel patients about recurrence risk and fall risk, especially elderly patients 5
• Home safety assessment is important, particularly between diagnosis and definitive treatment 5

Syncope vs. Dizziness:

• If patient had complete loss of consciousness with inability to maintain postural tone, this is syncope, not dizziness 5
• Evaluate for cardiac causes, orthostatic hypotension, and reflex syncope 5