What is the initial workup for a patient presenting with vertigo?

Workup for Vertigo

The initial workup for vertigo should be guided by classifying the presentation into one of four vestibular syndromes based on timing and triggers, followed by targeted physical examination maneuvers and selective imaging based on whether central or peripheral pathology is suspected. 1, 2

Step 1: Classify by Timing and Triggers

The first critical step is determining which vestibular syndrome pattern the patient exhibits 1, 2:

• Triggered episodic (<1 minute): Brief episodes provoked by specific head position changes suggest BPPV, superior canal dehiscence, or perilymphatic fistula 1, 2
• Spontaneous episodic (minutes to hours): Unprovoked episodes lasting 20 minutes to hours suggest Ménière's disease, vestibular migraine, or vertebrobasilar insufficiency 1, 2
• Acute vestibular syndrome (days): Continuous severe vertigo lasting days suggests vestibular neuritis, labyrinthitis, or posterior circulation stroke 1, 2
• Chronic (weeks to months): Persistent symptoms suggest anxiety disorder, medication effects, or posterior fossa mass 1

Step 2: Differentiate Peripheral vs. Central Causes

Key Historical Features

Peripheral vertigo indicators 3:

• Auditory symptoms (tinnitus, fluctuating hearing loss, aural fullness) strongly favor peripheral causes 3
• Episodes triggered by specific head movements 1
• No neurologic symptoms beyond vertigo 3

Central vertigo red flags 4, 2, 3:

• Severe postural instability (inability to stand or walk) out of proportion to vertigo 2, 3
• Cranial nerve deficits (diplopia, dysphagia, dysarthria) 3
• Age >50 with vascular risk factors 3
• Neurologic symptoms (weakness, numbness, speech changes) 5

Critical Physical Examination Maneuvers

For triggered episodic vertigo (suspected BPPV) 1, 2:

• Perform Dix-Hallpike maneuver: Positive test shows vertigo and nystagmus with 5-20 second latency, fatigable with repetition 2
• However, if Romberg test is positive, do NOT perform Dix-Hallpike first—this indicates central pathology requiring urgent imaging 4

For acute vestibular syndrome 6, 2:

• Perform HINTS examination (Head Impulse, Nystagmus, Test of Skew)—this has 92.9% sensitivity and 83.4% specificity for central causes when performed by trained clinicians 6
  • Head Impulse Test (HIT): Normal test (absence of corrective saccade) suggests central cause; abnormal test (corrective saccade present) suggests peripheral cause 4, 6
  • Nystagmus type: Direction-changing, pure vertical, or downward nystagmus indicates central cause; unidirectional horizontal-rotatory nystagmus suggests peripheral cause 4, 2, 6
  • Test of Skew: Vertical skew deviation indicates central cause 4, 6
• HINTS+ (HINTS with hearing assessment) has 99.0% sensitivity and 84.8% specificity for central causes 6

General neurologic examination 6:

• Limb weakness/hemiparesis: 11.4% sensitivity but 98.5% specificity for central cause 6
• Truncal/gait ataxia: Increasing severity correlates with central etiology (69.7% sensitivity, 83.7% specificity) 6
• Dysmetria: 24.6% sensitivity but 97.8% specificity for central cause 6

Step 3: Imaging Strategy

When to Image

Urgent MRI brain without and with IV contrast is indicated for 1, 4:

• Any patient with vertigo and positive Romberg test 4
• Central warning signs on HINTS examination (normal HIT, direction-changing nystagmus, or skew deviation) 4, 3
• Severe postural instability or inability to stand/walk 2, 3
• Any focal neurologic deficits 3
• Persistent vertigo failing to respond to 2-3 BPPV repositioning maneuvers 2

Rationale: MRI detects acute brain lesions in 11% of patients with acute persistent vertigo and no focal neurologic deficits, and 75-80% of patients with posterior circulation infarcts causing acute vestibular syndrome lack obvious focal neurologic deficits initially 4, 3

Imaging Modality Selection

For peripheral vertigo (episodic with auditory symptoms) 1:

• CT temporal bone without IV contrast detects temporal bone fractures, superior canal dehiscence, and bony labyrinth erosions 1
• MRI head and internal auditory canal (with or without IV contrast) detects labyrinthitis, vestibular schwannomas, and can demonstrate endolymphatic hydrops in Ménière's disease 1

For central vertigo concerns 1:

• MRI head and internal auditory canal without IV contrast (or with contrast) is first-line for persistent vertigo with neurologic symptoms 1
• MRA head and neck can detect vertebrobasilar insufficiency in episodic vertigo that cannot be confidently categorized as peripheral 1

What NOT to do 1, 4:

• CT head without contrast is inadequate for detecting CNS pathology in isolated vertigo and misses posterior fossa strokes in the acute phase 4
• Do not discharge patients with positive Romberg test and vertigo without imaging 4
• Do not treat empirically as BPPV without first excluding central causes when red flags are present 4

Common Pitfalls

• Assuming normal neurologic examination excludes stroke: Up to 75-80% of posterior circulation strokes causing vertigo may lack focal neurologic deficits initially 4, 3
• Misdiagnosing central causes as BPPV: CNS disorders masquerading as BPPV are found in 3% of treatment failures 2
• Relying solely on patient's description of "spinning": Focus on timing and triggers rather than specific descriptors, as these are more diagnostically useful 1
• Performing Dix-Hallpike when Romberg is positive: This indicates central pathology requiring imaging first 4