What is the approach to managing dizziness (vertigo)?

Approach to Dizziness

The initial approach to dizziness should focus on timing and triggers rather than the patient's subjective description, as this determines the diagnostic pathway and treatment. 1

Initial Classification by Timing

The first critical step is categorizing dizziness by temporal pattern, which has far greater diagnostic value than vague patient descriptions like "spinning" versus "lightheadedness" 1:

• Brief episodic vertigo: Seconds to minutes of vertigo triggered by head movements—strongly suggests BPPV 1
• Acute persistent vertigo: Days to weeks of constant symptoms—suggests vestibular neuritis or central causes 1
• Spontaneous episodic vertigo: Recurrent attacks lasting minutes to hours—suggests Ménière's disease or vestibular migraine 1
• Chronic vestibular syndrome: Persistent symptoms beyond weeks—requires evaluation for medication effects, psychiatric causes, or incomplete compensation 1, 2

History: Key Details to Elicit

Focus on specific triggers and associated symptoms rather than accepting vague descriptions 1:

• Positional triggers: Head movements, rolling over in bed, looking up (BPPV) 1
• Associated symptoms: Headache with photophobia/phonophobia suggests vestibular migraine 1; hearing loss, tinnitus, or aural fullness suggests Ménière's disease 1
• Medication review: Antihypertensives, sedatives, anticonvulsants, and psychotropic drugs are leading causes of chronic dizziness 2
• Vascular risk factors: Age >50, hypertension, diabetes, smoking—increase stroke risk 1
• Red flags: New severe headache, focal neurological deficits, sudden hearing loss, inability to stand/walk, or downbeating nystagmus mandate urgent evaluation 1

Physical Examination: Specific Maneuvers

For Brief Episodic Vertigo (Suspected BPPV)

• Dix-Hallpike maneuver: Gold standard for posterior canal BPPV (85-95% of cases), looking for latency of 5-20 seconds, torsional upbeating nystagmus toward affected ear, and symptoms resolving within 60 seconds 1, 3
• Supine roll test: If Dix-Hallpike negative, assess for lateral canal BPPV (10-15% of cases) by turning head rapidly 90° to each side while supine 3

For Acute Persistent Vertigo (Suspected Vestibular Neuritis vs. Stroke)

HINTS examination (Head Impulse, Nystagmus, Test of Skew) is more sensitive than early MRI for detecting posterior circulation stroke (100% vs 46% sensitivity) when performed by trained practitioners 1:

• Abnormal HINTS (normal head impulse, direction-changing nystagmus, or skew deviation) suggests central cause requiring immediate imaging 1
• Normal HINTS (abnormal head impulse, unidirectional horizontal nystagmus, no skew) suggests peripheral cause 1

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. The HINTS exam is essential but less reliable when performed by non-experts 1.

Orthostatic Assessment

• Measure blood pressure supine and after 3 minutes standing to assess for orthostatic hypotension 4

Imaging Decisions

No imaging is indicated for brief episodic vertigo with typical BPPV features or acute persistent vertigo with normal neurologic exam and HINTS consistent with peripheral vertigo by a trained examiner 1:

• MRI head without contrast is indicated for: abnormal neurologic examination, HINTS suggesting central cause, high vascular risk patients with acute vestibular syndrome, unilateral/pulsatile tinnitus, or asymmetric hearing loss 1
• CT head without contrast has very low yield (<1%) for isolated dizziness and misses most posterior circulation infarcts—should not substitute for MRI when stroke suspected 1

Treatment Algorithm by Diagnosis

BPPV (Most Common Cause)

Canalith repositioning procedures are first-line treatment with 80% success after 1-3 treatments and 90-98% after repeat maneuvers 5, 3:

• Posterior canal BPPV: Epley maneuver (80.5% negative Dix-Hallpike by day 7 vs 25% with Brandt-Daroff exercises) 5
• Lateral canal BPPV (geotropic): Barbecue roll or Gufoni maneuver 3
• Lateral canal BPPV (apogeotropic): Modified Gufoni maneuver 3
• Post-procedure: No activity restrictions needed—patients can resume normal activities immediately 3
• Medications: Do NOT prescribe vestibular suppressants (meclizine, antihistamines, benzodiazepines) for BPPV—no evidence of effectiveness and they interfere with central compensation 3, 2

Vestibular Neuritis

• Acute phase: Short-term vestibular suppressants only for severe nausea/vomiting (diazepam 10mg IM, methoclopramide 10mg IM) 6
• Subacute/chronic phase: Vestibular rehabilitation therapy to promote central compensation 5, 2

Persistent Dizziness After Treatment

Vestibular rehabilitation therapy is the primary intervention for persistent dizziness that has failed initial treatment, significantly improving gait stability compared to medication alone 5, 2:

• Indicated when balance and motion tolerance do not improve despite initial treatment 2
• Particularly beneficial for elderly patients, those with CNS disorders, or heightened fall risk 5
• Includes habituation exercises, gaze stabilization, balance retraining, and fall prevention 5

Critical Pitfalls to Avoid

• Do not rely on patient descriptions of "spinning" vs "lightheadedness"—focus on timing and triggers instead 1
• Do not assume normal neurologic exam excludes stroke—75-80% of posterior circulation strokes have no focal deficits 1
• Do not order routine imaging for isolated dizziness—yield is <1% and most findings are incidental 1
• Do not use CT instead of MRI when stroke suspected—CT misses most posterior circulation infarcts 1
• Do not prescribe vestibular suppressants long-term—they interfere with compensation and increase fall risk, especially in elderly 3, 2
• Do not skip HINTS examination in acute persistent vertigo—it's more sensitive than early MRI when performed correctly 1

Follow-Up Protocol

• Reassess within 1 month after initial treatment to document resolution or persistence 3, 2
• If symptoms persist: Repeat diagnostic testing, consider canal conversion (6-7% of cases), evaluate for multiple canal involvement, rule out coexisting vestibular dysfunction or CNS disorders 3, 2
• Counsel on recurrence: BPPV recurs in 10-18% at 1 year, up to 36% over time 2
• Fall prevention: Particularly important in elderly—36.7% with chronic vestibular disorders have BPPV, 53% have fallen in past year 2