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

Hospital Workup for Dizziness

The initial hospital workup for dizziness should focus on categorizing the presentation by timing and triggers through targeted history and physical examination, with imaging reserved only for red flag features suggesting central pathology. 1, 2

Initial Clinical Categorization

The first step is to classify dizziness into one of four vestibular syndromes based on timing, not the patient's vague description of symptoms 2, 3:

• Triggered Episodic Vestibular Syndrome (t-EVS): Brief episodes (seconds to <1 minute) triggered by head position changes—suggests BPPV 1
• Acute Vestibular Syndrome (AVS): Acute persistent dizziness lasting days to weeks with constant symptoms 1, 2
• Spontaneous Episodic Vestibular Syndrome: Recurrent episodes (minutes to hours) without positional triggers—suggests vestibular migraine or Ménière's disease 1
• Chronic Vestibular Syndrome: Persistent dizziness for weeks to months 2

Essential History Elements

Focus on duration, onset, and triggers rather than subjective symptom descriptions 2, 3:

• Duration of episodes: Seconds suggest BPPV, minutes to hours suggest vestibular migraine or Ménière's, days to weeks suggest AVS 1
• Positional triggers: Head position changes strongly suggest BPPV 1
• Associated otologic symptoms: Hearing loss, tinnitus, or aural fullness suggest Ménière's disease 4, 1
• Neurologic red flags: Headache, diplopia, dysarthria, numbness, weakness, or dysphagia suggest central pathology 4, 1
• Vascular risk factors: Hypertension, atrial fibrillation, diabetes, and age >45 increase stroke risk 2, 5
• Medication review: Many medications cause presyncope 6

Physical Examination

A complete neurologic examination including cranial nerves, cerebellar testing, and gait assessment is mandatory for all dizzy patients 1, 3:

• Observe for spontaneous nystagmus: Central patterns (downbeating, direction-changing, or purely vertical) indicate central pathology 1, 2
• Dix-Hallpike maneuver: Perform for suspected BPPV; positive test shows 5-20 second latency, torsional upbeating nystagmus toward the affected ear, and symptoms resolving within 60 seconds 1, 2, 3
• HINTS examination (Head Impulse, Nystagmus, Test of Skew): For AVS, this has 100% sensitivity for posterior circulation stroke when performed by trained practitioners, superior to early MRI (46% sensitivity) 2, 3
• Orthostatic vital signs: Check for orthostatic hypotension causing presyncope 6, 5

Laboratory Testing

Routine laboratory testing has extremely low yield in isolated dizziness with normal examination 1:

• Bedside glucose: Perform in all patients 5
• Pregnancy test: When clinically appropriate 1
• Avoid routine CBC, electrolytes, and BUN: These have low diagnostic yield unless specific clinical suspicion exists 5

Imaging Indications

Imaging is NOT routinely indicated for most dizziness cases 4, 2, 3. The detection rate of contributory CNS pathology in patients with normal neurologic examination is <1% 4.

MRI Brain (Without Contrast, With Diffusion-Weighted Imaging) is Indicated For:

• Focal neurological deficits 1, 2, 3
• HINTS examination suggesting central cause (normal head impulse test, direction-changing nystagmus, or positive skew deviation) 2, 3
• Sudden unilateral hearing loss 1, 3
• Inability to stand or walk 1
• Downbeating or other central nystagmus patterns 1, 2
• New severe headache 1
• High vascular risk patients with AVS, even with normal neurologic examination 2, 3
• Asymmetric hearing loss or unilateral/pulsatile tinnitus (to exclude vestibular schwannoma) 2, 3

Imaging is NOT Indicated For:

• Typical BPPV with positive Dix-Hallpike testing 4, 1, 2
• Isolated AVS with normal neurologic examination AND HINTS consistent with peripheral vertigo 4

Critical Pitfalls to Avoid

A normal neurologic examination does NOT exclude posterior circulation stroke—75-80% of patients with posterior circulation stroke have NO focal neurologic deficits 4, 1, 3. This is the most dangerous pitfall.

• Do not skip the Dix-Hallpike maneuver: It is the gold standard diagnostic test for BPPV 1, 2
• Do not use CT instead of MRI: CT has limited sensitivity for posterior circulation stroke 1, 2
• Do not order imaging for straightforward BPPV: This delays treatment unnecessarily 1, 3
• Do not rely on symptom quality alone: Timing and triggers are more diagnostically valuable 2, 3
• Approximately 4% of isolated dizziness cases are due to stroke, with 25% of AVS cases and up to 75% in high vascular risk cohorts being cerebrovascular 4, 2

Treatment Based on Diagnosis

• BPPV: Perform canalith repositioning procedure (Epley maneuver) with 90-98% success rate; counsel about 10-18% recurrence at 1 year 1, 2, 3
• Vestibular migraine: Initiate migraine prophylaxis and lifestyle modifications 1, 3
• Ménière's disease: Salt restriction and diuretics; consider intratympanic treatments for refractory cases 3
• Vestibular neuritis: Consider steroids 6