What is the approach to evaluating and managing chronic dizziness?

Workup of Chronic Dizziness

For chronic dizziness, focus your evaluation on timing and triggers rather than the patient's vague description of symptoms, perform targeted physical examination including Dix-Hallpike maneuver and neurologic testing, and reserve imaging only for red flag features—most cases do not require imaging. 1, 2

Step 1: Categorize by Timing Pattern

Classify the dizziness into one of four temporal patterns, as this drives your diagnostic approach 2, 3:

• Brief episodic (seconds to <1 minute): Triggered by specific head movements → suspect BPPV 2, 4
• Acute persistent (days to weeks): Constant symptoms → suspect vestibular neuritis or posterior circulation stroke 2
• Recurrent episodic (minutes to hours): Associated with headache, photophobia, phonophobia → suspect vestibular migraine 2, 3
• Chronic continuous (weeks to months): Persistent daily symptoms → suspect medication effects, psychiatric causes, or incomplete vestibular compensation 2, 5

Step 2: Identify Critical Associated Symptoms

Ask specifically about these features 2, 4:

• Hearing loss, tinnitus, or aural fullness: Suggests Ménière disease 2, 3
• Headache with migraine features: Suggests vestibular migraine 2, 3
• Focal neurologic symptoms (diplopia, dysarthria, numbness, weakness): Red flag for central pathology requiring urgent evaluation 2, 3
• Sudden unilateral hearing loss: Red flag requiring immediate workup 2, 4

Step 3: Perform Targeted Physical Examination

Execute these specific maneuvers 2, 4:

• Dix-Hallpike maneuver: Gold standard for BPPV diagnosis—positive if 5-20 second latency, torsional upbeating nystagmus toward affected ear, symptoms resolve within 60 seconds 2, 4
• Complete neurologic examination: Including cranial nerves, cerebellar testing (finger-to-nose, heel-to-shin, tandem gait), and gait assessment 4
• Observe for spontaneous nystagmus: Central patterns (downbeating, direction-changing) are red flags 2, 4
• Orthostatic vital signs: If presyncope suspected 6

Step 4: Review Medications and Screen for Psychiatric Causes

This is essential as these are leading causes of chronic dizziness 2:

• Medication review: Antihypertensives, sedatives, anticonvulsants, and psychotropic drugs are common culprits 2
• Psychiatric screening: Depression, anxiety, and panic disorder frequently cause chronic dizziness 2

Step 5: Determine Need for Imaging

Imaging is NOT routinely indicated for chronic dizziness. 2, 3 Order MRI brain without contrast only if these red flags are present 1, 2, 4:

• Focal neurological deficits
• Sudden unilateral hearing loss
• Inability to stand or walk
• Downbeating or other central nystagmus patterns
• New severe headache
• Progressive neurologic symptoms
• Unilateral or pulsatile tinnitus
• Asymmetric hearing loss
• High vascular risk with acute vestibular syndrome

CT head has very low diagnostic yield (<1%) for isolated dizziness and misses most posterior circulation infarcts—use MRI when central pathology is suspected. 1, 2, 4

Step 6: Establish Retrospective Diagnosis

Determine how the patient reached their current chronic state 5:

• Did symptoms start as BPPV, vestibular neuritis, vestibular migraine, Ménière disease, or brainstem stroke? 5
• Are original symptoms still present and requiring treatment? 5
• Has central vestibular compensation been impeded by visual problems, proprioceptive deficits, neurological disorders, or psychological factors? 5

Step 7: Initiate Appropriate Treatment

Based on diagnosis 2, 5:

• BPPV: Canalith repositioning (Epley maneuver) with 90-98% success rate—no medications needed 2, 4
• Vestibular migraine: Migraine prophylaxis and lifestyle modifications 2, 4
• Ménière disease: Salt restriction, diuretics, consider intratympanic treatments 2
• Incomplete compensation: Vestibular rehabilitation and counseling 5
• Medication-induced: Reduce or stop vestibular suppressants and tranquilizers 5

Critical Pitfalls to Avoid

• Do not rely on patient descriptions of "spinning" versus "lightheadedness"—timing and triggers are far more diagnostically valuable 2, 3
• Do not assume normal neurologic exam excludes stroke—75-80% of posterior circulation strokes present without focal deficits 2, 3
• Do not order imaging for straightforward BPPV with positive Dix-Hallpike and no concerning features—this delays treatment unnecessarily 2, 4
• Do not skip the Dix-Hallpike maneuver—it is the gold standard diagnostic test for BPPV 2, 4
• Do not order routine laboratory testing—it has extremely low yield in isolated dizziness with normal examination 4