What is the initial workup for a patient presenting with vertigo?

Initial Workup for Vertigo

Begin by classifying vertigo into one of four vestibular syndromes based on timing and triggers: triggered episodic (<1 minute), spontaneous episodic (minutes to hours), acute vestibular syndrome (days), or chronic (weeks to months), as this classification drives the entire diagnostic algorithm. 1

History: Focus on Timing and Triggers

• Triggered episodic vertigo (<1 minute) suggests BPPV, superior canal dehiscence, or perilymphatic fistula—brief episodes provoked by specific head position changes 1
• Spontaneous episodic vertigo (minutes to hours) points toward Ménière's disease, vestibular migraine, or vertebrobasilar insufficiency—unprovoked episodes lasting 20 minutes to hours 1
• Acute vestibular syndrome (days) indicates vestibular neuritis, labyrinthitis, or posterior circulation stroke—continuous severe vertigo lasting days 1
• Chronic vertigo (weeks to months) suggests anxiety disorder, medication effects, or posterior fossa mass 1

Physical Examination: Peripheral vs. Central Differentiation

Peripheral Vertigo Indicators

• Auditory symptoms (tinnitus, fluctuating hearing loss, aural fullness) strongly favor peripheral causes 2
• Horizontal or horizontal-rotatory nystagmus 2
• Episodes triggered by specific head movements 1
• No neurologic symptoms beyond vertigo 1

Central Vertigo Red Flags (Require Urgent Imaging)

• Severe postural instability out of proportion to vertigo 2
• Cranial nerve deficits (diplopia, dysphagia, dysarthria) 2
• Age >50 with vascular risk factors 1
• Pure vertical nystagmus 2

Critical Physical Examination Maneuvers

Romberg Test (Perform First)

• If Romberg is positive, DO NOT perform Dix-Hallpike—this indicates central pathology requiring urgent MRI brain without and with IV contrast 3
• A positive Romberg with vertigo mandates imaging before any repositioning maneuvers 3

HINTS Examination (for Acute Vestibular Syndrome)

• Perform Head Impulse, Nystagmus, Test of Skew examination if patient has acute persistent vertigo 3
• HINTS has 92.9% sensitivity and 83.4% specificity for central causes when performed by trained clinicians 1
• Central warning signs: absent head impulse test (normal head impulse), direction-changing nystagmus without head position changes, vertical skew deviation, or downward nystagmus in Dix-Hallpike 3, 2

Dix-Hallpike Maneuver (for Suspected BPPV)

• Only perform if Romberg is negative and no central red flags are present 3
• Tests for posterior canal BPPV—most common type 4
• May need to be repeated at a separate visit to avoid false-negative results 4

Supine Roll Test (for Lateral Canal BPPV)

• Perform if history compatible with BPPV but Dix-Hallpike is negative 4
• Lateral canal BPPV accounts for 10-15% of BPPV cases 4
• Look for geotropic (most common) or apogeotropic nystagmus 4

Imaging Strategy

When to Order Urgent MRI Brain Without and With IV Contrast

• Positive Romberg test with vertigo 3
• Central warning signs on HINTS examination 1
• Severe postural instability 1
• Focal neurologic deficits 1
• Persistent vertigo with neurologic symptoms 4

Critical pitfall: Up to 75-80% of posterior circulation strokes causing vertigo may lack focal neurologic deficits initially, so do not assume a normal neurologic examination excludes stroke 2

MRI Head and Internal Auditory Canal

• First-line for persistent vertigo with neurologic symptoms 4
• Detects acute brain lesions in 11% of patients with acute persistent vertigo and no focal neurologic deficits 3
• Can reveal central causes of vertigo when distinction from peripheral causes is needed 4

MRA Head and Neck

• Use for episodic vertigo that cannot be confidently categorized as peripheral to detect vertebrobasilar insufficiency 4

CT Temporal Bone Without IV Contrast

• Use for episodic peripheral vertigo with auditory symptoms when structural inner ear pathology is suspected 4
• CT head without contrast is inadequate for detecting CNS pathology in isolated vertigo and misses posterior fossa strokes in the acute phase 1, 3

Common Pitfalls to Avoid

• Never assume normal neurologic exam excludes stroke—most posterior circulation strokes causing vertigo lack obvious focal deficits 2
• Never perform Dix-Hallpike when Romberg is positive—image first 3
• Never discharge without imaging when Romberg is positive with vertigo 3
• Never treat empirically as BPPV without excluding central causes first—CNS disorders masquerade as BPPV in 3% of treatment failures 1
• Never rely solely on patient's description of "spinning"—focus on timing and triggers instead 1