What is the approach to evaluating and managing vertigo?

Evaluation of Vertigo

Classify vertigo by timing and triggers rather than symptom quality, then perform targeted physical examination with the Dix-Hallpike maneuver for episodic positional symptoms or HINTS examination for acute persistent symptoms—this approach identifies the cause without routine imaging or vestibular testing. 1, 2

Initial Classification by Timing and Triggers

The diagnostic framework depends on categorizing vertigo into three syndromes based on temporal patterns 1, 2:

• Triggered episodic vestibular syndrome: Brief episodes (seconds to minutes) provoked by specific head movements or position changes, most commonly indicating BPPV 1, 2
• Spontaneous episodic vestibular syndrome: Recurrent episodes lasting minutes to hours without positional triggers, suggesting vestibular migraine or Ménière's disease 2
• Acute vestibular syndrome (AVS): Continuous symptoms lasting days to weeks with nausea, vomiting, and gait instability 1, 2

Do not rely on patient descriptions of "spinning" versus "lightheadedness"—these subjective characterizations are diagnostically unreliable. 2 Instead, focus on duration, onset pattern, specific triggers, and associated symptoms like hearing loss, tinnitus, aural fullness, headache, photophobia, or phonophobia 2.

Physical Examination Approach

For Triggered Episodic Symptoms (Suspected BPPV)

Perform the Dix-Hallpike maneuver as the gold standard diagnostic test by bringing the patient from upright to supine with head turned 45° to one side and neck extended 20° with the affected ear down 3, 1. A positive test shows:

• Latency period of 5-20 seconds before symptoms begin 2
• Torsional, upbeating nystagmus toward the affected ear 3, 1
• Vertigo and nystagmus that increase then resolve within 60 seconds 3, 2

If the first side is negative, repeat with the opposite ear down before concluding the test is negative 3. A positive Dix-Hallpike test confirms posterior canal BPPV and eliminates the need for imaging or vestibular testing. 1, 2

For Acute Vestibular Syndrome

Use the HINTS examination (Head-Impulse, Nystagmus, Test of Skew) to distinguish peripheral from central causes, which has 100% sensitivity for detecting stroke when performed by trained practitioners—superior to early MRI (46% sensitivity) 1, 2. However, recognize that HINTS performed by non-experts is less reliable 2.

Central features requiring urgent evaluation include 2:

• Normal head impulse test (suggests central pathology)
• Direction-changing nystagmus with gaze
• Vertical skew deviation
• Downbeating nystagmus

Critical pitfall: 75-80% of patients with posterior circulation stroke from acute vestibular syndrome have no focal neurologic deficits, so a normal neurologic exam does not exclude stroke 2.

When to Order Imaging

Do not order imaging for typical BPPV with positive Dix-Hallpike test and no additional concerning features. 1, 2 Routine imaging for isolated dizziness has very low yield (<1% for CT) and most findings are incidental 2.

Indications for MRI brain without contrast 1, 2:

• Abnormal neurologic examination
• HINTS examination suggesting central cause
• High vascular risk patients with acute vestibular syndrome
• Unilateral or pulsatile tinnitus
• Asymmetric hearing loss
• Atypical nystagmus patterns
• New severe headache accompanying dizziness (requires immediate imaging and neurologic consultation)
• Progressive symptoms suggesting mass lesion

CT head has poor sensitivity (20-40%) for posterior circulation infarcts and should not substitute for MRI when stroke is suspected. 2 CT may be appropriate only as initial screening in acute settings before MRI 2.

Red Flags Requiring Urgent Evaluation

The following mandate immediate further workup 1, 2:

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

Treatment Considerations

For BPPV

Perform canalith repositioning procedures (Epley maneuver) as first-line treatment, with success rates of 90-98% when additional maneuvers are performed for persistent cases 1. Vestibular rehabilitation exercises can serve as initial treatment or adjunct therapy 1. Medications are unnecessary for typical BPPV. 3

For Symptom Management

Meclizine 25-100 mg daily in divided doses is FDA-approved for vertigo associated with vestibular system diseases 4, though it causes drowsiness and has anticholinergic effects 4. Use with caution in patients with asthma, glaucoma, or prostate enlargement 4.

Follow-Up and Patient Counseling

Reassess patients within one month after initial treatment to document resolution or persistence of symptoms. 1 If symptoms persist, evaluate for unresolved BPPV or underlying peripheral vestibular or central nervous system disorders 3.

Counsel patients about 3, 1:

• Recurrence risk: 5-13.5% at 6 months, 10-18% at 1 year, up to 36% long-term 1
• Fall risk: BPPV significantly increases fall risk, particularly in elderly patients—assess home safety and consider activity restrictions until resolved 3
• Importance of returning promptly if symptoms recur for repeat repositioning procedures 3

Common Pitfalls to Avoid

• Ordering comprehensive vestibular testing for straightforward BPPV—this is unnecessary and delays treatment 2
• Assuming normal neurologic exam excludes stroke in acute vestibular syndrome 2
• Using CT instead of MRI when central causes are suspected 2
• Prescribing medications for typical BPPV instead of performing repositioning maneuvers 3, 1
• Failing to perform appropriate positional testing before ordering imaging 2