What is the approach to assessing vertigo?

Approach to Assessment of Vertigo

Definition

Vertigo is a false sensation of self-motion or the illusion that the visual surroundings are spinning or rotating, indicating dysfunction of the vestibular system or its central connections. 1, 2 This differs from non-vertiginous dizziness (lightheadedness, presyncope, disequilibrium), which suggests cardiovascular, metabolic, or psychiatric causes rather than vestibular pathology. 2

Classification

By Timing Pattern (Vestibular Syndromes)

• Triggered Episodic Vestibular Syndrome (t-EVS): Brief episodes (<1 minute) provoked by specific head movements or position changes; most commonly BPPV 1, 3
• Spontaneous Episodic Vestibular Syndrome (s-EVS): Recurrent episodes (minutes to hours) without positional triggers; includes vestibular migraine and Ménière's disease 3
• Acute Vestibular Syndrome (AVS): Continuous vertigo lasting days; includes vestibular neuritis (most common peripheral cause) and posterior circulation stroke 3
• Chronic Vestibular Syndrome: Persistent symptoms lasting weeks to months 1

By Anatomic Location

• Peripheral vertigo: Inner ear pathology (BPPV, vestibular neuritis, Ménière's disease, labyrinthitis) 4, 5
• Central vertigo: Brainstem or cerebellar pathology (stroke, demyelination, tumor) 4, 5

Differential Diagnosis

Peripheral Causes (Most Common)

• BPPV: 42% of all vertigo cases in primary care; brief positional episodes without hearing loss 3, 1
• Vestibular neuritis: Acute continuous vertigo lasting days without hearing loss 3
• Ménière's disease: Episodic vertigo (20 minutes to 12 hours) with fluctuating hearing loss, tinnitus, and aural fullness 3
• Labyrinthitis: Similar to vestibular neuritis but includes hearing loss 3
• Superior canal dehiscence: Pressure-induced (not position-induced) vertigo with conductive hearing loss 3

Central Causes (Life-Threatening)

• Posterior circulation stroke: Critical to exclude; 75-80% have no focal neurologic deficits on standard exam 3
• Transient ischemic attack 4, 6
• Multiple sclerosis 4
• Cerebellar hemorrhage or infarction 4
• Intracranial neoplasms 4

Non-Vestibular Causes

• Postural hypotension: Provoked by supine-to-upright position change 3
• Medication side effects: Antihypertensives, cardiovascular drugs, anticonvulsants, CNS depressants 3
• Anxiety/panic disorders: Vague lightheadedness, though actual vestibular dysfunction may coexist 3

History Taking

Character and Timing (Critical Framework)

Focus exclusively on timing and triggers rather than patient descriptors of dizziness type, as patients cannot reliably describe symptom quality. 3, 2

• Onset: Sudden vs. gradual 7
• Duration: Seconds, minutes, hours, or days 4, 7
• Frequency: Single episode vs. recurrent attacks 7
• Triggers: Head position changes, standing up, specific movements, loud sounds, pressure changes 8, 7
• Confirm true vertigo: Ask "Do you feel like you or the room is spinning?" 8, 2

Associated Symptoms

• Otologic: Hearing loss, tinnitus, aural fullness, ear pain 3, 7
• Neurologic: Diplopia, dysarthria, facial numbness, limb weakness, sensory changes, headache 3, 7
• Autonomic: Nausea, vomiting 7
• Loss of consciousness: Never occurs with vestibular disorders; indicates different etiology 2

Red Flags (Require Urgent Evaluation)

• Focal neurological deficits: Diplopia, dysarthria, facial numbness, limb weakness, sensory changes 3, 8
• Inability to stand or walk independently 3
• New severe headache with dizziness 3
• Sudden unilateral hearing loss with vertigo 3
• Downbeating nystagmus or other central nystagmus patterns 3
• Presence of syncope (excludes peripheral causes) 6

Risk Factors and Comorbidities

• Age >65 years: 12-fold increased fall risk; BPPV prevalence increases with age 1
• History of head trauma: Posttraumatic BPPV requires repeated repositioning procedures in 67% of cases 1
• Comorbidities: Diabetes (14% vs. 5% in controls), hypertension (52% vs. 22%), migraine (34% vs. 10%), stroke history (10% vs. 1%) 1
• Fall history: Ask about falls in past year, unsteadiness, fear of falling 1

Physical Examination (Focused)

Neurologic Examination

• Cranial nerves: Assess for focal deficits 4, 7
• Motor and sensory function: Limb strength, coordination, sensation 4
• Cerebellar testing: Finger-to-nose, heel-to-shin, gait assessment 4
• Romberg test: Assess balance 6

Nystagmus Assessment

• Spontaneous nystagmus: Observe with and without visual fixation 4
• Central pattern: Nystagmus that does not lessen with visual fixation, downbeating, or purely vertical 4, 3
• Peripheral pattern: Horizontal-torsional, suppressed by visual fixation 4

Specific Diagnostic Maneuvers

• Dix-Hallpike maneuver: Diagnoses posterior canal BPPV; positive test shows transient upbeating-torsional nystagmus 1, 8
• Supine roll test: Diagnoses lateral canal BPPV 1
• Head impulse test: Assesses vestibulo-ocular reflex; abnormal in peripheral vestibular loss 6
• HINTS examination (Head Impulse, Nystagmus, Test of Skew): Differentiates central from peripheral causes in acute vestibular syndrome 8

Cardiovascular Examination

• Orthostatic vital signs: Rule out postural hypotension 3
• Cardiac auscultation: Assess for arrhythmias 4

Investigations and Expected Findings

When Imaging is NOT Indicated

Do not obtain radiographic imaging in patients who meet diagnostic criteria for BPPV with typical Dix-Hallpike findings in the absence of additional signs/symptoms inconsistent with BPPV. 1, 8

When Imaging IS Indicated

• MRI with diffusion-weighted imaging (DWI): First-line for suspected central causes, focal neurologic deficits, or atypical presentations 1, 3, 8
  • Expected findings: Ischemic stroke (most common), hemorrhage, neoplasm, demyelination 1
  • Diagnostic yield: 4% in isolated dizziness, 12% with associated neurologic findings 1
• CT temporal bone: First-line for suspected conductive hearing loss, superior canal dehiscence, or temporal bone pathology 1
  • Expected findings: Otosclerosis, ossicular erosion, superior semicircular canal dehiscence 1
• Do not use CT head for stroke evaluation in dizziness—MRI with DWI is required 3

Vestibular Testing

Do not order vestibular testing in patients who meet diagnostic criteria for BPPV in the absence of additional vestibular signs/symptoms inconsistent with BPPV. 1

• Audiometry: Indicated for hearing loss, tinnitus, or suspected Ménière's disease 3, 6
  • Expected findings: Sensorineural hearing loss in Ménière's disease, conductive loss in superior canal dehiscence 3
• Videonystagmography (VNG): For persistent symptoms or diagnostic uncertainty 6
• Vestibular evoked myogenic potentials (VEMP): For suspected superior canal dehiscence 3

Laboratory Tests

• Generally not indicated unless specific systemic causes suspected (e.g., glucose for hypoglycemia, CBC for anemia) 7

Empiric Treatment

BPPV (Most Common)

Treat posterior canal BPPV with canalith repositioning procedure (Epley maneuver); success rate 90-98% when performed correctly. 1, 8

• Do not recommend postprocedural postural restrictions after canalith repositioning 1
• Observation with follow-up is an acceptable alternative for initial management 1
• Do not routinely treat BPPV with vestibular suppressants (antihistamines, benzodiazepines) 1
• Vestibular rehabilitation (self-administered or with clinician) may be offered 1

Acute Vestibular Neuritis

• Vestibular suppressants: Short-term use (48-72 hours) for severe symptoms 9
  • Diazepam 10 mg IM once or twice daily 9
  • Antihistamines (meclizine, dimenhydrinate) 9
  • Antiemetics (metoclopramide 10 mg IM, prochlorperazine) 9
• Early vestibular rehabilitation: Begin after acute phase to promote central compensation 9
• Corticosteroids: May be considered in first 72 hours 9

Ménière's Disease

• Dietary sodium restriction (<1500-2000 mg/day) 3
• Diuretics: Hydrochlorothiazide or acetazolamide 3
• Acute attacks: Vestibular suppressants and antiemetics 9

Vestibular Migraine

• Migraine prophylaxis: Beta-blockers, calcium channel blockers, tricyclic antidepressants 3
• Lifestyle modifications: Trigger avoidance, sleep hygiene 3

Indications to Refer

Urgent/Emergency Referral

• Any red flag symptoms: Focal neurologic deficits, inability to walk, severe headache, sudden hearing loss 3, 8
• Suspected posterior circulation stroke or TIA 3, 4
• Central nystagmus patterns 3, 4

Routine Referral to ENT/Neurotology

• BPPV refractory to treatment: Persistent symptoms after 1 month or multiple failed repositioning attempts 1, 3
• Suspected Ménière's disease: For audiometry and specialized management 3
• Suspected superior canal dehiscence: For VEMP testing and potential surgical management 3
• Diagnostic uncertainty: When peripheral vs. central differentiation is unclear 1

Referral to Neurology

• Suspected central causes: Stroke, demyelination, migraine 4
• Atypical presentations with negative ENT workup 4

Referral to Vestibular Rehabilitation

• Persistent symptoms despite treatment 1
• Chronic vestibular syndrome 1
• Elderly patients with fall risk 1

Outcome Assessment and Follow-Up

Reassess patients within 1 month after initial observation or treatment to document resolution or persistence of symptoms. 1

• If symptoms persist: Evaluate for unresolved BPPV and/or underlying peripheral vestibular or central nervous system disorders 1
• Patient education: Discuss BPPV recurrence risk, fall prevention, importance of reporting atypical symptoms 1, 8

Critical Pitfalls

Diagnostic Pitfalls

• Do not rely on patient descriptions of dizziness type—focus exclusively on timing and triggers, as patients cannot accurately describe symptom quality 3, 2
• Do not assume normal neurologic exam excludes stroke in acute vestibular syndrome—75-80% of posterior circulation infarcts have no focal deficits on standard examination 3
• Do not use CT head for stroke evaluation in dizziness—MRI with diffusion-weighted imaging is required for adequate sensitivity 3
• Do not miss atypical BPPV presentations that may represent central pathology (CPPV)—patients with negative or atypical Dix-Hallpike testing are at increased risk for central causes 1

Management Pitfalls

• Do not order imaging or vestibular testing for typical BPPV with positive Dix-Hallpike maneuver—this wastes resources and delays treatment 1, 8
• Do not prescribe vestibular suppressants routinely for BPPV—they are ineffective and delay recovery 1
• Do not recommend postural restrictions after Epley maneuver—evidence shows no benefit 1
• Do not overlook fall risk assessment in elderly patients with BPPV—9% of geriatric clinic patients have undiagnosed BPPV, and three-fourths had fallen within 3 months 1

Special Population Pitfalls

• Elderly patients: Vertigo is often multifactorial; carefully evaluate for comorbidities (diabetes, hypertension, stroke history) and fall risk 1, 6
• Posttraumatic BPPV: Requires repeated repositioning procedures in 67% of cases vs. 14% for non-traumatic BPPV 1
• Patients with impaired mobility or CNS disorders: Require modified management approach and increased fall precautions 1