What is the workup for chronic intermittent vertigo?

Workup for Chronic Intermittent Vertigo

The workup for chronic intermittent vertigo should be guided by a systematic clinical evaluation focusing on timing, triggers, and associated symptoms, with imaging reserved only for patients with red flags suggesting central pathology. 1, 2

Initial Clinical Assessment

History Taking - Key Elements

The most diagnostically valuable information comes from characterizing the timing and triggers rather than the patient's subjective description of "dizziness" or "spinning": 2

• Duration of episodes: Seconds (<1 minute) suggests BPPV, minutes to hours suggests Ménière's disease or vestibular migraine, hours to days suggests vestibular neuritis 1, 2, 3
• Triggers: Position changes point to BPPV, spontaneous episodes suggest Ménière's disease or vestibular migraine 2, 3
• Associated symptoms:
  • Unilateral hearing loss, tinnitus, or aural fullness strongly suggest Ménière's disease 1, 2
  • Headache with photophobia/phonophobia suggests vestibular migraine 2
  • Neurological symptoms (diplopia, dysarthria, dysphagia, weakness) are red flags for central pathology 1, 2

Medication Review

Perform a comprehensive medication review, as polypharmacy is a leading reversible cause of chronic vestibular syndrome, particularly antihypertensives, sedatives, anticonvulsants, and psychotropic medications. 2

Psychiatric Screening

Screen for anxiety, panic disorder, and depression, as these are common causes of chronic dizziness that may mimic or coexist with vestibular disorders. 2

Physical Examination

Essential Vestibular Testing

• Dix-Hallpike maneuver: Gold standard for BPPV diagnosis, looking for latency of 5-20 seconds, provoked vertigo and nystagmus that increase then resolve within 60 seconds, and rotatory nystagmus beating toward the affected ear 2, 3
• Supine roll test: For horizontal canal BPPV 2
• Nystagmus assessment: Direction-changing nystagmus without head position changes, downbeating nystagmus, or gaze-holding nystagmus are red flags for central pathology 1, 2

Neurological Examination

Perform focused neurological examination looking for:

• Focal deficits (weakness, sensory changes, cerebellar signs) 1, 2
• Gait and postural stability assessment 4
• Cranial nerve examination, particularly eye movements 4

Audiologic Testing

Obtain comprehensive audiologic examination for patients with unilateral tinnitus, persistent symptoms, or associated hearing difficulties. 2 This is particularly important as unilateral hearing loss requires thorough investigation to exclude retrocochlear pathology. 5

Imaging Decisions

When Imaging is NOT Indicated

No imaging is routinely indicated for chronic intermittent vertigo in the absence of red flags. 1, 2 Specifically, imaging is unnecessary for:

• Typical BPPV with positive Dix-Hallpike test and no additional concerning features 2
• Peripheral vestibular disorders with normal neurologic examination 6, 2

The diagnostic yield of routine imaging in isolated dizziness is extremely low (<1% for CT), and most findings are incidental. 2

When Imaging IS Indicated - Red Flags

MRI brain without contrast (NOT CT) should be obtained when any of the following red flags are present: 1, 2

• Focal neurological deficits 2
• Sudden unilateral hearing loss 2
• Inability to stand or walk despite being alert 7
• Downbeating nystagmus or other central nystagmus patterns 1, 2
• Unilateral or pulsatile tinnitus 2
• Progressive neurologic symptoms suggesting mass lesion 2
• New severe headache accompanying vertigo 7, 2
• Failure to respond to appropriate vestibular treatments 2

Imaging Modality Selection

• MRI brain without contrast is the preferred imaging modality, with significantly higher diagnostic yield (4-16%) compared to CT (20-40% sensitivity), particularly for posterior circulation pathology 1, 2
• CT temporal bone without contrast may be appropriate specifically for suspected superior semicircular canal dehiscence or when evaluating for vestibular aqueduct stenosis in Ménière's disease 1
• MRA head and neck should be added if vertebral artery dissection is suspected 1, 7

Vestibular Function Testing

Comprehensive vestibular testing is NOT routinely indicated for straightforward cases (e.g., typical BPPV), as it is unnecessary and delays treatment. 2

Vestibular testing may be appropriate only when:

• Clinical presentation is atypical 2
• Dix-Hallpike findings are equivocal 2
• Additional symptoms suggest concurrent CNS or otologic disorders 2

Common Diagnostic Pitfalls to Avoid

• Do not rely solely on patient descriptions of "spinning" versus "lightheadedness" - focus instead on timing, triggers, and associated symptoms 2
• Do not assume normal neurologic exam excludes stroke - 75-80% of patients with acute vestibular syndrome from posterior circulation infarct have no focal neurologic deficits 2
• Do not order routine imaging for isolated dizziness without red flags - the yield is extremely low 2
• Do not use CT instead of MRI when stroke is suspected, as CT misses many posterior circulation infarcts 2
• Do not order comprehensive vestibular testing for straightforward BPPV 2

Specific Diagnostic Considerations

Ménière's Disease

For chronic recurrent vertigo with unilateral hearing loss or tinnitus, Ménière's disease should be considered. 1 The diagnosis is primarily clinical, with episodes of vertigo, fluctuating sensorineural hearing loss, tinnitus, and aural fullness. 1 MRI of the internal auditory canal is typically performed to exclude other causes (vestibular schwannoma, superior semicircular dehiscence) rather than to make a positive diagnosis. 1

Benign Paroxysmal Positional Vertigo

Episodes lasting seconds only (<1 minute) with position changes are pathognomonic for BPPV. 2 A positive Dix-Hallpike maneuver is diagnostic, and no imaging or additional vestibular testing is needed for typical cases. 2

Vestibular Migraine

Headache with photophobia and phonophobia accompanying vertigo episodes suggests vestibular migraine. 2 This is a clinical diagnosis that does not require imaging in the absence of red flags. 1