What is the initial workup and management for a patient presenting with dizziness?

Initial Workup for Dizziness

The initial workup for dizziness should focus on categorizing the presentation by timing and triggers—not the patient's subjective description—into one of four vestibular syndromes, followed by targeted bedside examination and selective imaging only when red flags are present. 1, 2

Step 1: Categorize by Timing and Triggers

Ignore vague patient descriptions like "spinning" versus "lightheadedness" and instead classify into these syndromes 1, 2:

• Acute Vestibular Syndrome (AVS): Constant dizziness lasting days to weeks 1
• Triggered Episodic Vestibular Syndrome: Seconds to minutes of symptoms provoked by head movements (suggests BPPV) 1, 2
• Spontaneous Episodic Vestibular Syndrome: Minutes to hours of recurrent episodes without triggers (suggests vestibular migraine or Ménière's disease) 1
• Chronic Vestibular Syndrome: Persistent symptoms for weeks to months 1

Step 2: Obtain Focused History

Key elements to elicit 1, 2:

• Duration and onset: Seconds suggests BPPV; minutes to hours suggests migraine or Ménière's; days suggests vestibular neuritis or stroke 1
• Positional triggers: Head movements triggering symptoms strongly suggest BPPV 1, 3
• Associated otologic symptoms: Hearing loss, tinnitus, or aural fullness suggest Ménière's disease 1, 2
• Neurological red flags: Headache, diplopia, dysarthria, numbness, weakness, or inability to walk suggest central causes 1, 2
• Vascular risk factors: Hypertension, atrial fibrillation, diabetes increase stroke risk 1
• Medication review: Antihypertensives, sedatives, anticonvulsants are common culprits in chronic dizziness 2

Step 3: Perform Targeted Physical Examination

For all patients 1, 3:

• Observe for spontaneous nystagmus (direction, pattern) 1
• Complete neurologic examination to identify focal deficits 1

For suspected BPPV (triggered episodic pattern) 4, 1:

• Dix-Hallpike maneuver: Diagnostic criteria include 5-20 second latency, torsional upbeating nystagmus toward affected ear, symptoms resolving within 60 seconds 2, 3
• Supine roll test: For horizontal canal BPPV 1

For acute vestibular syndrome 1, 2:

• HINTS examination (Head Impulse, Nystagmus, Test of Skew): When performed by trained practitioners, this has 100% sensitivity for detecting stroke versus 46% for early MRI 2
• Critical caveat: HINTS is unreliable when performed by non-experts 2

Step 4: Determine Need for Imaging

No imaging needed for 1, 2, 3:

• Typical BPPV with positive Dix-Hallpike test and no atypical features 1, 2
• Acute vestibular syndrome with normal neurologic exam AND peripheral HINTS findings by trained examiner 2

MRI brain without contrast is indicated for 1, 2:

• Acute persistent vertigo with abnormal neurologic examination 1, 2
• HINTS examination suggesting central cause 1, 2
• High vascular risk patients with acute vestibular syndrome, even with normal neurologic exam 1
• Unilateral or pulsatile tinnitus 1
• Asymmetric hearing loss 1
• Progressive symptoms suggesting mass lesion 2
• New severe headache accompanying dizziness 2

Avoid CT head: CT has very low diagnostic yield (<1%) for isolated dizziness and only 20-40% sensitivity for posterior circulation infarcts 2

Step 5: Initiate Treatment Based on Diagnosis

For BPPV 4, 2, 3:

• Perform canalith repositioning procedures (Epley maneuver) with 90-98% success rate 2, 3
• No medications or imaging needed for typical cases 2, 3
• Reassess within one month 2

For vestibular neuritis 1:

• Vestibular rehabilitation exercises 5
• Short-term vestibular suppressants may be considered 6

For orthostatic hypotension causing dizziness 4:

• In heart failure patients stable on guideline-directed medical therapy, dizziness is unlikely related to HF medications—evaluate for other causes 4
• Patient education about transient dizziness as side effect of life-prolonging medications 4
• Consider diuretic reduction if no signs of congestion 4

Critical Pitfalls to Avoid

Common errors that lead to misdiagnosis 1, 2:

• Relying on patient's description of symptom quality: Focus on timing and triggers instead 1, 2
• Assuming normal neurologic exam excludes stroke: 75-80% of patients with posterior circulation infarct from acute vestibular syndrome have no focal neurologic deficits 2
• Failing to perform Dix-Hallpike maneuver: This leads to unnecessary imaging and missed BPPV diagnosis 1, 2
• Ordering routine imaging for isolated dizziness: Diagnostic yield is only 4%, and most findings are incidental 1, 2
• Using CT instead of MRI when stroke suspected: CT misses many posterior circulation infarcts 2
• Performing HINTS examination without proper training: Results are unreliable when done by non-experts 2

Red Flags Requiring Urgent Evaluation

Immediate imaging and neurology consultation needed for 1, 2:

• Focal neurological deficits 1, 2
• Sudden hearing loss 2
• Inability to stand or walk 2
• Downbeating nystagmus or other central nystagmus patterns 2
• New severe headache 2
• Failure to respond to appropriate vestibular treatments 2

Patient Education and Follow-Up

Counsel patients about 4:

• BPPV recurrence risk: 10-18% at one year, up to 36% long-term 4
• Fall risk, particularly in elderly patients (53% of elderly with vestibular disorders fall within one year) 4
• Home safety assessment and activity restrictions until symptoms resolve 4
• Importance of returning promptly if symptoms recur for repeat repositioning procedures 2
• Atypical symptoms warranting re-evaluation: persistent nausea, vomiting, gait disturbance, or nonpositional vertigo 4