What is the initial approach to evaluating a patient presenting with dizziness?

Initial Evaluation of Dizziness

The initial approach to evaluating dizziness should categorize patients by timing and triggers rather than symptom quality, as this framework more accurately distinguishes benign peripheral vestibular disorders from dangerous central causes like stroke. 1, 2

Step 1: Categorize by Timing and Triggers (Not Symptom Quality)

The outdated approach of asking patients to describe their dizziness as "spinning" versus "lightheadedness" is unreliable and should be abandoned. 1, 2 Instead, classify patients into one of three temporal patterns:

Brief Episodic Vertigo (Seconds to Minutes)

• Episodes last <1 minute and are triggered by specific head movements 1
• Most likely diagnosis: Benign Paroxysmal Positional Vertigo (BPPV) 1, 2
• Perform Dix-Hallpike maneuver immediately—this is the gold standard diagnostic test 1, 2
• Positive findings: 5-20 second latency, torsional upbeating nystagmus toward affected ear, symptoms resolve within 60 seconds 1, 2

Acute Vestibular Syndrome (Days to Weeks)

• Constant symptoms lasting days with acute onset 1, 2
• Critical action: Perform HINTS examination (Head Impulse, Nystagmus, Test of Skew) if you are trained 1, 2
• HINTS has 100% sensitivity for posterior circulation stroke when performed by trained practitioners, superior to early MRI (46% sensitivity) 1, 2
• Major pitfall: 75-80% of patients with posterior circulation stroke have NO focal neurologic deficits, so normal neurologic exam does NOT exclude stroke 1, 2

Spontaneous Episodic Vertigo (Minutes to Hours)

• Recurrent episodes without positional triggers 1, 2
• Associated headache, photophobia, phonophobia suggest vestibular migraine 1
• Associated hearing loss, tinnitus, aural fullness suggest Ménière's disease 1, 2

Step 2: Focused History Elements

Obtain specific details rather than vague descriptions:

• Duration and onset: Seconds vs. minutes vs. hours vs. days 1, 2
• Triggers: Head position changes, standing up, specific movements 1, 2
• Associated symptoms:
  • Hearing loss, tinnitus, aural fullness (Ménière's disease) 1, 2
  • Headache, photophobia, phonophobia (vestibular migraine) 1, 2
  • Neurologic symptoms (stroke warning) 1, 2
• Medication review: Antihypertensives, sedatives, anticonvulsants, psychotropics are leading causes of chronic dizziness 1
• Fall history: Ask specifically about falls in past year, unsteadiness, fear of falling 3

Step 3: Targeted Physical Examination

For Brief Episodic Vertigo (Suspected BPPV)

• Dix-Hallpike maneuver for posterior canal BPPV 1, 2
• Supine roll test for horizontal canal BPPV 1, 2
• Do NOT order imaging or vestibular testing if Dix-Hallpike is positive with typical findings 1

For Acute Vestibular Syndrome

• HINTS examination (only if trained—unreliable when performed by non-experts) 1, 2
  • Head impulse test: Normal test (no corrective saccade) suggests central cause 4
  • Nystagmus: Direction-changing nystagmus or downbeating nystagmus suggests central cause 4
  • Test of skew: Vertical skew deviation suggests central cause 4
• Complete neurologic examination including cranial nerves, cerebellar testing, gait assessment 2
• Romberg test: Positive Romberg with vertigo indicates central pathology, not peripheral 4

For All Patients

• Otologic examination 1
• Gait and balance assessment 3, 2
• Orthostatic vital signs if presyncope suspected 5

Step 4: Red Flags Requiring Urgent Evaluation

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

• Focal neurological deficits 1, 2
• Sudden hearing loss 1, 2
• Inability to stand or walk 1, 2
• Downbeating nystagmus or other central nystagmus patterns 1, 2
• New severe headache 1
• Abnormal HINTS examination suggesting central cause 1, 2
• Positive Romberg test with vertigo 4

Step 5: Imaging Decisions

NO Imaging 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 trained examiner 1

MRI Brain Without Contrast Indicated

• Abnormal neurologic examination 1, 2
• HINTS examination suggesting central cause 1, 2
• High vascular risk patients with acute vestibular syndrome 1, 2
• Unilateral or pulsatile tinnitus 1, 2
• Asymmetric hearing loss 1, 2
• Positive Romberg test with vertigo 4

Critical Imaging Pitfall

CT head has very low diagnostic yield (<1%) for isolated dizziness and misses most posterior circulation infarcts—use MRI with diffusion-weighted imaging instead 1, 4

Step 6: Initial Management Based on Diagnosis

BPPV (Most Common)

• Canalith repositioning procedures (Epley maneuver) are first-line treatment with 90-98% success rates 1, 2
• No medications needed for typical BPPV 1
• Counsel about 10-18% recurrence rate at 1 year, up to 36% long-term 2

Vestibular Neuritis

• Steroids may be beneficial 5
• Vestibular rehabilitation 5

Ménière's Disease

• Salt restriction and diuretics 1, 2
• Intratympanic treatments for refractory cases 1, 2

Vestibular Migraine

• Migraine prophylaxis and lifestyle modifications 1, 2

Critical Pitfalls to Avoid

• Do not rely on patient's description of "spinning" vs "lightheadedness"—focus on timing and triggers instead 1, 2
• Do not assume normal neurologic exam excludes stroke—most posterior circulation strokes have no focal deficits 1, 2
• Do not perform HINTS examination if untrained—results are unreliable 1, 2
• Do not use CT instead of MRI when stroke is suspected 1, 4
• Do not order routine imaging for isolated dizziness—yield is extremely low 1
• Do not treat empirically as BPPV if Romberg test is positive—this indicates central pathology requiring imaging 4
• Do not forget fall risk assessment in elderly patients with BPPV—12-fold increased fall risk 3