Guidelines for Evaluating and Managing Dizziness
Begin by categorizing dizziness based on timing and triggers rather than the patient's subjective description, as this approach is more diagnostically valuable and guides targeted management. 1, 2
Initial Categorization Framework
Classify dizziness into one of four temporal patterns to narrow your differential diagnosis: 1, 2
- Brief episodic vertigo: Seconds to minutes, triggered by head movements (think BPPV) 1
- Triggered episodic vestibular syndrome: Episodes lasting minutes to hours with specific triggers 1
- Acute vestibular syndrome (AVS): Days to weeks of constant symptoms 1
- Chronic vestibular syndrome: Persistent symptoms beyond weeks 1
Critical History Elements
Focus your questioning on these specific details rather than vague descriptions like "spinning" versus "lightheadedness": 1, 2
- Duration and onset: How long do episodes last? Sudden or gradual? 2
- Triggers: Positional changes, head movements, pressure changes, specific activities 1, 2
- Associated symptoms: 2
A critical pitfall: 75-80% of patients with posterior circulation stroke have NO focal neurologic deficits, so a normal neurologic exam does NOT exclude stroke. 2
Physical Examination Essentials
For Brief Episodic Vertigo (Suspected BPPV)
- Perform the Dix-Hallpike maneuver as the gold standard diagnostic test 1, 2
- Positive findings include: 1
- Latency period of 5-20 seconds before symptoms begin
- Torsional, upbeating nystagmus toward the affected ear
- Vertigo and nystagmus that increase then resolve within 60 seconds
For Acute Vestibular Syndrome
Perform the HINTS examination (Head Impulse, Nystagmus, Test of Skew) if you are trained, as it has 100% sensitivity for detecting posterior circulation stroke—superior to early MRI which has only 46% sensitivity. 1, 2 However, when performed by non-experts, HINTS is less reliable and should not be relied upon. 1
Complete Neurologic Assessment
Perform cranial nerve testing, cerebellar testing (finger-to-nose, heel-to-shin, rapid alternating movements), and gait assessment for all patients. 2
Imaging Decisions
NO Imaging Indicated For:
- Brief episodic vertigo with typical BPPV features and positive Dix-Hallpike test 1
- Acute persistent vertigo with normal neurologic exam AND HINTS consistent with peripheral vertigo (when performed by trained examiner) 1
MRI Brain Without Contrast (with diffusion-weighted imaging) Indicated For:
- 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
- Any red flag symptoms (see below) 2
Avoid CT head for dizziness evaluation: CT has very low diagnostic yield (<1%) for isolated dizziness and only 20-40% sensitivity for detecting causative pathology, particularly missing posterior circulation infarcts. 1 If imaging is needed, MRI is vastly superior. 1
Red Flags Requiring Urgent Evaluation
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, 2
- Failure to respond to appropriate vestibular treatments 1
Treatment Based on Diagnosis
Benign Paroxysmal Positional Vertigo (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, 2 No imaging or medication is needed for typical cases. 1 Counsel patients about 10-18% recurrence rate at 1 year, up to 36% long-term. 2
Ménière's Disease
Manage with salt restriction and diuretics as initial therapy. 1, 2 Consider intratympanic treatments (dexamethasone or gentamicin) for refractory cases. 2, 3
Vestibular Migraine
Treat with migraine prophylaxis and lifestyle modifications. 1, 2
Vestibular Neuritis
Consider steroids for acute management. 3
Diagnostic Testing
Audiometry
Obtain comprehensive audiologic examination for: 1
- Unilateral tinnitus
- Persistent symptoms
- Associated hearing difficulties
- Suspected Ménière's disease
Vestibular Testing
Do NOT order vestibular testing for straightforward BPPV with positive Dix-Hallpike test, as it is unnecessary and delays treatment. 1 Reserve vestibular testing for atypical presentations, equivocal Dix-Hallpike findings, or when additional symptoms suggest concurrent CNS or otologic disorders. 1
Medication Review and Chronic Dizziness
For chronic vestibular syndrome, medication review is essential as it is a leading cause. 1 Specifically assess: 1
- Antihypertensives
- Sedatives
- Anticonvulsants
- Psychotropic drugs
Screen for psychiatric symptoms (anxiety, panic disorder, depression), as these are common causes of chronic dizziness. 1 Avoid long-term use of vestibular suppressant medications, as they interfere with natural balance recovery and should only be used for acute symptom management. 4
Vestibular Rehabilitation
Emphasize vestibular rehabilitation exercises for many peripheral and central etiologies, as they improve balance, reduce fall risk, and promote central compensation mechanisms. 4, 5
Special Consideration for Heart Failure Patients
If a patient is on guideline-directed medical therapy for heart failure with reduced ejection fraction, dizziness is unlikely related to HF therapy—consider other etiologies such as BPPV, vestibular disorders, or valvular disease instead. 2
Common Pitfalls to Avoid
- Relying on patient's description of "spinning" versus "lightheadedness" instead of focusing on timing and triggers 1, 2
- Assuming normal neurologic exam excludes stroke (remember: 75-80% of posterior circulation strokes have no focal deficits) 2
- Ordering routine imaging for isolated dizziness (very low yield, mostly incidental findings) 1
- Using CT instead of MRI when stroke is suspected 1
- Failing to perform Dix-Hallpike maneuver for suspected BPPV 2
- Not assessing fall risk in elderly patients with vestibular disorders 2