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

Evaluation of Dizziness

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

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

Avoid the traditional approach of asking patients to describe their dizziness as "spinning" versus "lightheadedness"—this is unreliable and does not differentiate benign from dangerous causes. 1, 2 Instead, classify into one of three vestibular syndromes:

Acute Vestibular Syndrome (AVS)

• Acute persistent vertigo lasting days to weeks with constant symptoms 1, 2
• Key examination: HINTS (Head Impulse, Nystagmus, Test of Skew) 1, 2
• HINTS has 100% sensitivity for posterior circulation stroke when performed by trained practitioners, superior to early MRI (46% sensitivity) 1, 2
• Critical pitfall: 75-80% of patients with posterior circulation stroke have NO focal neurologic deficits, so normal neurologic exam does NOT exclude stroke 1, 2

Triggered Episodic Vestibular Syndrome

• Brief episodes lasting seconds to <1 minute triggered by head movements 1, 2
• Perform Dix-Hallpike maneuver and supine roll test 1, 2
• Most commonly BPPV—if positive Dix-Hallpike with typical findings (5-20 second latency, torsional upbeating nystagmus toward affected ear, symptoms resolve within 60 seconds), no imaging or further testing needed 1, 2

Spontaneous Episodic Vestibular Syndrome

• Episodes lasting minutes to hours without positional triggers 1, 2
• Associated symptoms guide diagnosis: headache, photophobia, phonophobia suggest vestibular migraine 1
• Hearing loss, tinnitus, aural fullness suggest Ménière's disease 1, 2

Step 2: Focused History Elements

Duration and onset: Seconds (BPPV), minutes to hours (vestibular migraine, Ménière's), days to weeks (vestibular neuritis, stroke) 1, 2

Triggers: Head position changes (BPPV), pressure changes (superior canal dehiscence), none (vestibular neuritis, stroke) 1, 2

Associated symptoms:

• Hearing loss, tinnitus, aural fullness → Ménière's disease 1, 2
• Headache, photophobia, phonophobia → vestibular migraine 1
• Sudden hearing loss → urgent evaluation required 1, 2

Medication review: Essential, as medications (antihypertensives, sedatives, anticonvulsants, psychotropics) are a leading cause of chronic dizziness 1

Vascular risk factors: Hypertension, diabetes, smoking, atrial fibrillation increase stroke risk 1, 2

Step 3: Targeted Physical Examination

Complete neurologic examination (all patients):

• Cranial nerves, cerebellar testing (finger-to-nose, heel-to-shin, rapid alternating movements), gait assessment 1, 2
• Do not assume normal exam excludes stroke—this is a dangerous pitfall 1, 2

HINTS examination (for AVS, only if trained):

• Head Impulse Test: Normal (no corrective saccade) suggests central cause 1, 3
• Nystagmus: Direction-changing or downbeating suggests central cause 1, 3
• Test of Skew: Vertical skew deviation suggests central cause 1, 3
• If HINTS performed by non-experts, results are unreliable—proceed to imaging 1

Dix-Hallpike maneuver (for triggered episodic symptoms):

• Positive test: 5-20 second latency, torsional upbeating nystagmus toward affected ear, symptoms resolve within 60 seconds 1, 2
• Do not perform if Romberg test is positive—this suggests central pathology requiring imaging first 3

Romberg test:

• Positive Romberg with vertigo indicates central rather than peripheral pathology 3
• Requires urgent MRI brain without and with contrast 3

Orthostatic vital signs:

• Check for orthostatic hypotension if presyncope suspected 4

Fall risk assessment (especially elderly):

• Ask: (1) Have you fallen in the past year? (2) Do you feel unsteady? (3) Do you worry about falling? 5
• Positive responses warrant detailed falls risk assessment (Get Up and Go test, Tinetti Balance Assessment) 5

Step 4: 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, 2

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 (use MRI without and with contrast) 3

CT head has very low yield:

• <1% diagnostic yield for isolated dizziness 1
• Only 20-40% sensitivity for posterior circulation infarcts 1
• Should not be used instead of MRI when stroke suspected 1
• May be appropriate before MRI in acute settings, but does not exclude stroke 1

Step 5: Red Flags Requiring Urgent Evaluation

• 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 (mandates immediate imaging and neurologic consultation) 1
• Failure to respond to appropriate vestibular treatments 1, 2

Step 6: Initial Management Based on Diagnosis

BPPV (most common):

• Canalith repositioning procedures (Epley maneuver) as first-line treatment 1, 2
• Success rates 90-98% with additional maneuvers if needed 1
• No medications or imaging needed for typical cases 1, 2
• Counsel about 10-18% recurrence at 1 year, up to 36% long-term 2

Vestibular neuritis:

• Steroids may be beneficial 4
• Vestibular rehabilitation 4

Ménière's disease:

• Salt restriction and diuretics 1, 2
• Intratympanic dexamethasone or gentamicin for refractory cases 1, 4

Vestibular migraine:

• Migraine prophylaxis and lifestyle modifications 1, 2

Posterior circulation stroke:

• Activate stroke protocol immediately 3
• Urgent neurology consultation 3

Common Pitfalls to Avoid

• Relying on patient's description of "spinning" vs "lightheadedness" instead of focusing on timing and triggers 1, 2
• Assuming normal neurologic exam excludes stroke—75-80% of posterior circulation strokes have no focal deficits 1, 2
• Failing to perform Dix-Hallpike maneuver when positional symptoms are present 2
• Using CT instead of MRI when stroke is suspected—CT misses many posterior circulation infarcts 1
• Routine imaging for isolated dizziness—has low yield and most findings are incidental 1
• Treating empirically as BPPV without proper examination—may miss dangerous central causes 3
• Not assessing fall risk in elderly patients with vestibular disorders—BPPV increases fall risk 12-fold 5