What investigations should be ordered for a patient presenting with vertigo?

Investigations for Vertigo

For most patients with vertigo, the diagnosis is made through targeted history and bedside examination maneuvers—not laboratory tests or imaging—and routine neuroimaging or vestibular testing should be avoided unless specific red flags are present. 1, 2

Initial Clinical Assessment (No Testing Required)

The first step is determining the timing pattern of vertigo, which guides all subsequent decisions 2, 3:

• Brief episodic vertigo (seconds to minutes, triggered by head movement): Suggests BPPV and requires only the Dix-Hallpike maneuver 1, 2
• Acute persistent vertigo (days to weeks of constant symptoms): Suggests vestibular neuritis or stroke; requires HINTS examination 1, 2
• Spontaneous episodic vertigo (recurrent episodes without triggers): Suggests Ménière's disease or vestibular migraine; requires audiometry 1, 2
• Chronic vestibular syndrome (persistent disequilibrium): Requires medication review and psychiatric screening 2

Bedside Examination (The Most Important "Tests")

For Brief Episodic Vertigo (Suspected BPPV)

Perform the Dix-Hallpike maneuver—this is more diagnostic than any imaging or laboratory test. 1, 2, 3

• Positive findings include: 5-20 second latency, rotatory nystagmus beating toward the affected ear, symptoms that increase then resolve within 60 seconds 2, 3
• If positive for BPPV: No imaging, no vestibular testing, no laboratory work is indicated. 1, 2
• Proceed directly to Epley maneuver treatment 3

For Acute Persistent Vertigo (Suspected Vestibular Neuritis vs. Stroke)

Perform the HINTS examination (Head Impulse, Nystagmus, Test of Skew)—when performed by trained practitioners, this has 100% sensitivity for stroke detection, superior to early MRI (46% sensitivity). 1, 2, 4

HINTS examination components 1, 2, 4:

• Head Impulse Test (HIT): Normal (corrective saccade) suggests central/stroke; abnormal suggests peripheral 4
• Nystagmus pattern: Bidirectional, vertical, direction-changing, or pure torsional nystagmus indicates central cause (98.5% specificity) 4
• Test of Skew: Skew deviation indicates central cause (97.6% specificity) 4

Critical caveat: HINTS performed by non-experts has mixed reliability—if expertise is unavailable, proceed to imaging 1, 2

When to Order Imaging

MRI Brain Without Contrast (Preferred Imaging)

Order MRI with diffusion-weighted imaging for: 1, 2

• Acute persistent vertigo with abnormal neurologic examination 1, 2
• HINTS examination suggesting central cause (even with normal neurologic exam) 1, 2
• High vascular risk patients with acute vestibular syndrome 1
• Focal neurologic deficits (weakness, dysmetria, ataxia) 1, 2, 5
• Progressive symptoms suggesting mass lesion 2
• Unilateral tinnitus or asymmetric hearing loss (rule out cerebellopontine angle tumor) 1, 2
• Pulsatile tinnitus 2
• New severe headache accompanying dizziness 2

MRI has 4-16% diagnostic yield in appropriate patients, vastly superior to CT. 6

CT Head Without Contrast

CT has very low diagnostic yield (<1%) for isolated dizziness and only 20-40% sensitivity for posterior circulation infarcts. 1, 6

• May be used only as initial screening in acute settings when MRI is unavailable and stroke is suspected 1, 6
• Should not be used instead of MRI when stroke is suspected, as CT misses most posterior circulation infarcts 2, 6

When NOT to Order Imaging

Do not order imaging for: 1, 2

• Typical BPPV with positive Dix-Hallpike test and no neurologic deficits 1, 2
• Acute persistent vertigo with normal neurologic exam AND HINTS consistent with peripheral vertigo by trained examiner 1, 2
• Isolated dizziness without red flags 1, 6

Audiometric Testing

Order comprehensive audiologic examination for: 1, 2

• Unilateral tinnitus 2
• Fluctuating hearing loss, tinnitus, or aural fullness (suspected Ménière's disease) 1, 2
• Persistent vestibular symptoms with hearing difficulties 2
• Asymmetric hearing loss 2

Vestibular Function Testing

Do not order comprehensive vestibular testing for straightforward BPPV—it is unnecessary and delays treatment. 1, 2

Consider vestibular testing only if: 1, 2

• Clinical presentation is atypical 1
• Dix-Hallpike findings are equivocal or unusual 1
• Additional symptoms suggest concurrent CNS or otologic disorders 1
• Multiple concurrent peripheral vestibular disorders suspected 1
• Patient fails to respond to appropriate treatment 2

Laboratory Testing

Routine neurological laboratory testing is not indicated for most patients with vertigo. 6

Consider laboratory work only for specific scenarios: 6

• CBC, basic metabolic panel, glucose if orthostatic hypotension or dehydration suspected 6
• Syphilis serology if neurosyphilis suspected with sensory ataxia and risk factors 6

Red Flags Requiring Urgent Evaluation and Imaging

Any of these findings mandate immediate MRI and neurologic consultation: 2, 7

• Focal neurological deficits 2, 7
• Sudden hearing loss 2
• Inability to stand or walk 2
• Downbeating nystagmus or other central nystagmus patterns 2
• New severe headache 2, 7
• Failure to respond to appropriate vestibular treatments 2

Critical Pitfalls to Avoid

Do not assume a normal neurologic exam excludes stroke—75-80% of patients with acute vestibular syndrome from posterior circulation infarct have no focal neurologic deficits. 1, 2

Do not rely on patient descriptions of "spinning" versus "lightheadedness"—focus instead on timing, triggers, and associated symptoms. 1, 2

Do not order routine imaging for isolated dizziness—most findings are incidental with very low diagnostic yield. 1, 2, 6

Do not perform comprehensive vestibular testing before attempting the Dix-Hallpike maneuver in suspected BPPV. 1