What is the appropriate management for a patient presenting with dizziness?

Management of Dizziness

Categorize dizziness by timing and triggers—not by the patient's subjective description—to determine the specific vestibular syndrome, then perform targeted bedside examinations (Dix-Hallpike for triggered symptoms, HINTS for acute persistent symptoms) before considering any imaging. 1

Initial Clinical Categorization

The American Academy of Otolaryngology-Head and Neck Surgery framework divides dizziness into four vestibular syndromes based on temporal patterns 1, 2:

• Triggered Episodic Vestibular Syndrome (t-EVS): Seconds to minutes of symptoms provoked by head movements—think BPPV 3
• Acute Vestibular Syndrome (AVS): Days to weeks of constant, persistent dizziness 1, 2
• Spontaneous Episodic Vestibular Syndrome: Recurrent episodes without clear triggers—consider Ménière's disease or vestibular migraine 2
• Chronic Vestibular Syndrome: Persistent symptoms lasting months 3

Critical History Elements

Focus on these specific details rather than vague descriptions 2, 3:

• Duration and onset: Seconds suggests BPPV; hours suggests Ménière's or vestibular migraine; days to weeks suggests vestibular neuritis or stroke 1, 2
• Triggers: Positional changes point to BPPV; no trigger with acute onset raises concern for stroke 1, 3
• Associated symptoms: Hearing loss/tinnitus suggests Ménière's disease; headache with photophobia suggests vestibular migraine; neurologic symptoms (diplopia, dysarthria, weakness) indicate central pathology 1, 2, 3

Physical Examination Protocol

For Triggered Episodic Symptoms (Suspected BPPV)

Perform the Dix-Hallpike maneuver immediately—this is the gold standard diagnostic test 3:

• Positive findings: 5-20 second latency, torsional upbeating nystagmus toward the affected ear, symptoms resolving within 60 seconds 2, 3
• If positive with typical features, no imaging or vestibular testing is needed—proceed directly to treatment 3
• Perform supine roll test for horizontal canal BPPV 1, 2

For Acute Vestibular Syndrome (Constant Symptoms)

The HINTS examination (Head Impulse, Nystagmus, Test of Skew) is mandatory and has 100% sensitivity for posterior circulation stroke when performed by trained practitioners—superior to early MRI which has only 46% sensitivity 1, 3:

• Critical pitfall: 75-80% of patients with posterior circulation stroke have NO focal neurologic deficits, so a normal neurologic exam does NOT exclude stroke 1, 3
• If you are not trained in HINTS, assume central pathology and obtain urgent MRI 3
• HINTS suggesting peripheral cause: abnormal head impulse test, unidirectional horizontal nystagmus, no skew deviation 1
• HINTS suggesting central cause: normal head impulse test, direction-changing or vertical nystagmus, skew deviation present 1, 3

Complete Neurologic Examination

Perform cranial nerve testing, cerebellar testing (finger-to-nose, heel-to-shin), and gait assessment for all patients 1, 2

Imaging Decisions

When Imaging is NOT Indicated

• Typical BPPV with positive Dix-Hallpike and no red flags 1, 3
• Acute vestibular syndrome with normal neurologic exam AND HINTS consistent with peripheral vertigo by a trained examiner 3
• Clear peripheral causes with appropriate response to treatment 1

The diagnostic yield of CT in isolated dizziness is less than 1%, with sensitivity of only 20-40% for causative pathology 4, 3. CT particularly misses posterior circulation infarcts 3.

When MRI Brain Without Contrast is Indicated

MRI with diffusion-weighted imaging is the preferred study 1, 2:

• Abnormal neurologic examination 1, 2
• HINTS examination suggesting central cause 1, 3
• High vascular risk patients (hypertension, atrial fibrillation, diabetes) with acute vestibular syndrome, even with normal neurologic exam 1, 3
• Unilateral or pulsatile tinnitus 1, 3
• Asymmetric hearing loss 1, 3
• Focal neurological deficits 1
• New severe headache 3
• Inability to stand or walk 1, 3
• Downbeating nystagmus or other central nystagmus patterns 1, 3

MRI diagnostic yield in isolated dizziness is 4%, with ischemic stroke being the most common finding (70% of positive cases), two-thirds in posterior circulation 3.

Treatment Based on Diagnosis

BPPV (Most Common Peripheral Cause)

Perform canalith repositioning procedures (Epley maneuver) immediately—this is first-line treatment with 90-98% success rate 2, 3:

• No medications are needed for typical BPPV 3, 5
• Meclizine 25-100 mg daily may be used for symptomatic relief in vestibular disorders but does not treat the underlying cause 5
• Counsel patients about recurrence risk: 10-18% at one year, up to 36% long-term 1, 2
• Reassess within one month to document resolution 3

Ménière's Disease

• Salt restriction and diuretics as first-line 1, 2
• Consider intratympanic treatments for refractory cases 1, 2

Vestibular Migraine

• Migraine prophylaxis and lifestyle modifications 1, 2

Vestibular Neuritis

• Vestibular rehabilitation exercises 1
• Short-term vestibular suppressants may provide symptomatic relief but can delay central compensation 6

Chronic Vestibular Syndrome

Medication review is essential—antihypertensives, sedatives, anticonvulsants, and psychotropic drugs are leading causes 3:

• Screen for psychiatric symptoms (anxiety, panic disorder, depression) 3
• Consider vestibular rehabilitation 6
• MRI only if progressive symptoms or red flags present 3

Red Flags Requiring Urgent Evaluation

These mandate immediate imaging (MRI preferred) and neurologic consultation 1, 3:

• Focal neurological deficits 1, 3
• Sudden hearing loss 1, 3
• Inability to stand or walk 1, 3
• New severe headache 3
• Downbeating nystagmus or other central nystagmus patterns 1, 3
• Failure to respond to appropriate vestibular treatments 3

Common Pitfalls to Avoid

• Do not rely on patient descriptions of "spinning" versus "lightheadedness"—focus on timing and triggers instead 3
• Do not assume normal neurologic exam excludes stroke—most posterior circulation strokes present without focal deficits 1, 3
• Do not use CT when stroke is suspected—it misses most posterior circulation infarcts 3
• Do not order imaging for typical BPPV with positive Dix-Hallpike—this delays treatment unnecessarily 3
• Do not skip the Dix-Hallpike maneuver in patients with triggered episodic symptoms 1, 3
• Do not perform HINTS if untrained—unreliable results may lead to missed strokes 3
• Do not forget fall risk assessment, especially in elderly patients with vestibular disorders 1, 2

Special Consideration: 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—evaluate for BPPV, vestibular disorders, or valvular disease instead 1