What is the approach to diagnosing and treating dizziness and vertigo?

Approach to Dizziness and Vertigo

Focus on timing and triggers—not the patient's subjective description of "spinning" versus "lightheadedness"—to categorize dizziness into specific vestibular syndromes that guide diagnosis and treatment. 1, 2

Initial Clinical Categorization

Classify dizziness into one of four vestibular syndromes based on temporal patterns 1, 2:

• Acute Vestibular Syndrome (AVS): Continuous vertigo lasting days to weeks 1, 2
• Triggered Episodic Vestibular Syndrome (t-EVS): Brief episodes (seconds to minutes) provoked by specific head movements or positional changes 1, 2
• Spontaneous Episodic Vestibular Syndrome (s-EVS): Recurrent episodes (minutes to hours) without specific triggers 1, 2
• Chronic Vestibular Syndrome: Persistent symptoms lasting months 1, 2

This timing-based approach is superior to the outdated method of relying on symptom quality descriptions, which leads to misdiagnosis 1, 3.

Essential History Elements

Obtain specific details that narrow the differential 1, 2:

• Duration: Seconds suggest BPPV; minutes to hours suggest vestibular migraine or Ménière's; days suggest vestibular neuritis or stroke 1, 4
• Triggers: Head position changes (BPPV), pressure changes (superior canal dehiscence), or no trigger (vestibular neuritis, stroke) 1, 2
• Associated symptoms: Hearing loss/tinnitus/aural fullness (Ménière's disease), headache/photophobia/phonophobia (vestibular migraine), neurological symptoms (stroke) 1, 2
• Medication review: Antihypertensives, sedatives, anticonvulsants, and psychotropic drugs are leading causes of chronic dizziness 1
• Vascular risk factors: Hypertension, atrial fibrillation, diabetes increase stroke risk 2

Physical Examination Protocol

For Triggered Episodic Vertigo (Suspected BPPV)

• Dix-Hallpike maneuver: Gold standard for posterior canal BPPV; positive test shows 5-20 second latency, transient upbeating-torsional nystagmus toward affected ear, and symptoms resolving within 60 seconds 1, 4
• Supine roll test: Evaluates horizontal canal BPPV 1, 2
• No imaging or vestibular testing needed for typical BPPV with positive Dix-Hallpike and no red flags 1

For Acute Vestibular Syndrome

Perform HINTS examination (Head Impulse, Nystagmus, Test of Skew) when trained 1:

• Sensitivity of 100% versus 46% for early MRI in detecting posterior circulation stroke when performed by experts 1
• Critical caveat: HINTS is unreliable when performed by non-experts; in this case, proceed directly to MRI 1
• Complete neurologic examination: However, recognize that 75-80% of posterior circulation infarcts have NO focal neurologic deficits on standard exam 1, 4

General Examination

• Observe for spontaneous nystagmus in all patients 2
• Assess gait and balance 1
• Complete otologic examination including hearing assessment 1

Imaging Decisions

When NO Imaging is Indicated

• Brief episodic vertigo with typical BPPV features and positive Dix-Hallpike 1, 2
• Acute persistent vertigo with normal neurologic exam AND HINTS consistent with peripheral vertigo by a trained examiner 1

When MRI Brain Without Contrast is Recommended

• Acute persistent vertigo with abnormal neurologic examination 1, 2
• HINTS examination suggesting central cause 1, 2
• High vascular risk patients with acute vestibular syndrome, even with normal neurologic exam 2
• Unilateral tinnitus, pulsatile tinnitus, or asymmetric hearing loss (to exclude vestibular schwannoma; use MRI with contrast for internal auditory canal) 1, 2
• Progressive symptoms suggesting mass lesion 1

Critical Imaging Pitfalls

• CT head has very low yield (<1%) for isolated dizziness and only 20-40% sensitivity for posterior circulation infarcts 1, 2
• Never use CT instead of MRI when stroke is suspected—CT misses most posterior circulation infarcts 1
• MRI with diffusion-weighted imaging has 4% diagnostic yield in isolated dizziness, with 70% of positive findings being ischemic stroke 2

Red Flags Requiring Urgent Evaluation

Any of these mandate immediate MRI and neurologic consultation 1, 2:

• Focal neurological deficits: Diplopia, dysarthria, facial numbness, limb weakness, sensory changes 1, 4
• New severe headache with dizziness 1
• Sudden unilateral hearing loss with vertigo 1
• Inability to stand or walk independently 1
• Downbeating nystagmus or other central nystagmus patterns 1
• Failure to respond to appropriate vestibular treatments 1

Treatment by Diagnosis

BPPV (Most Common Cause—42% of Vertigo Cases)

• Canalith repositioning procedures (Epley maneuver) are first-line treatment 1, 4
• No imaging or medication needed for typical cases 1
• Meclizine 25-100 mg daily in divided doses may suppress symptoms but does not cure BPPV 5

Vestibular Neuritis (Most Common Peripheral Cause of AVS)

• Supportive care with vestibular suppressants (meclizine 25-100 mg daily) for acute phase only 4, 5
• Early vestibular rehabilitation is crucial 1
• Symptoms last days without hearing loss 4

Ménière's Disease

• Salt restriction and diuretics as first-line management 1
• Intratympanic treatments for refractory cases 1
• Episodes last 20 minutes to 12 hours with fluctuating hearing loss and aural fullness 4

Vestibular Migraine

• Migraine prophylaxis and lifestyle modifications 1
• Diagnosed when ≥5 episodes (5 minutes to 72 hours) occur with migraine features in ≥50% of episodes 4

Posterior Circulation Stroke

• Immediate MRI with diffusion-weighted imaging and neurologic consultation 1, 2
• Approximately 4% of isolated dizziness cases are due to stroke 2

Common Diagnostic Pitfalls to Avoid

• Do not rely on patient descriptions of "spinning" versus "lightheadedness"—these are unreliable 1, 4
• Do not assume normal neurologic exam excludes stroke—75-80% of posterior circulation infarcts have no focal deficits 1, 4
• Do not order routine imaging for isolated dizziness without red flags—yield is extremely low 1, 2
• Do not order comprehensive vestibular testing for straightforward BPPV—it delays treatment unnecessarily 1
• Do not use CT when stroke is suspected—it misses most posterior circulation infarcts 1
• Do not perform HINTS examination unless properly trained—unreliable results lead to missed strokes 1

Medication Considerations

Meclizine (vestibular suppressant) 5:

• Dosage: 25-100 mg daily in divided doses for vertigo associated with vestibular system diseases 5
• Use with caution: Causes drowsiness; avoid driving or operating machinery 5
• Anticholinergic effects: Prescribe carefully in asthma, glaucoma, or prostate enlargement 5
• Drug interactions: Increased CNS depression with alcohol or other CNS depressants; potential interactions with CYP2D6 inhibitors 5
• Use only for acute symptom suppression, not as definitive treatment for BPPV or chronic conditions 1