What is the initial assessment and treatment approach for patients presenting with vertigo or dizziness?

Assessment for Vertigo vs Dizziness

Initial Classification Using Timing and Triggers

Focus on timing and triggers rather than the patient's subjective description of "spinning" versus "lightheadedness" to categorize dizziness into specific vestibular syndromes. 1, 2 This approach is more diagnostically valuable than vague symptom descriptions and guides all subsequent evaluation and management decisions. 1, 2

Four Vestibular Syndrome Categories

Classify every patient into one of these four syndromes based on duration and triggers: 1, 3

• Triggered Episodic Vestibular Syndrome (t-EVS): Seconds to <1 minute of vertigo provoked by specific head position changes—suspect BPPV, superior canal dehiscence, or perilymphatic fistula 1, 3

• Spontaneous Episodic Vestibular Syndrome: Minutes to hours of unprovoked vertigo—suspect Ménière's disease (with hearing loss/tinnitus/aural fullness), vestibular migraine (with headache/photophobia/phonophobia), or vertebrobasilar insufficiency 1, 2, 3

• Acute Vestibular Syndrome (AVS): Days to weeks of continuous severe vertigo—suspect vestibular neuritis, labyrinthitis, or posterior circulation stroke 1, 3

• Chronic Vestibular Syndrome: Weeks to months of persistent symptoms—suspect medication effects (antihypertensives, sedatives, anticonvulsants, psychotropics), anxiety/panic disorder, or posterior fossa mass 2, 3

Critical History Elements

Obtain these specific details rather than accepting vague descriptions: 1, 2

• Duration and onset: Exact timing of symptom onset and how long each episode lasts 1
• Positional triggers: Does lying down, rolling over, bending down, or tilting the head back provoke symptoms? 4
• Associated auditory symptoms: Hearing loss, tinnitus, or aural fullness suggest Ménière's disease 1, 2
• Neurological red flags: Headache, diplopia, dysarthria, numbness, weakness, or inability to stand/walk mandate urgent evaluation 1, 2
• Medication review: Essential screening as medications are a leading cause of chronic dizziness 2
• Vascular risk factors: Age >50, hypertension, atrial fibrillation, diabetes increase stroke risk 1

Physical Examination Approach

Observe for Spontaneous Nystagmus First

Examine all patients for spontaneous nystagmus before performing any maneuvers. 1 Central patterns (downbeating, direction-changing without gaze, purely vertical) indicate CNS pathology requiring immediate imaging. 1, 2

For Triggered Episodic Symptoms (Suspected BPPV)

Perform the Dix-Hallpike maneuver as the gold standard diagnostic test: 1, 3

• Positive findings: 5-20 second latency, torsional upbeating nystagmus toward the affected ear, symptoms that increase then resolve within 60 seconds 1, 3
• If Dix-Hallpike is negative but history suggests BPPV, perform the supine roll test for lateral canal BPPV (10-15% of cases) 3
• Do NOT order neuroimaging or vestibular testing for typical BPPV with positive Dix-Hallpike and no red flags—this delays treatment unnecessarily 2, 3

For Acute Vestibular Syndrome (Continuous Vertigo)

Perform the HINTS examination (Head Impulse, Nystagmus, Test of Skew) if you are trained in this technique: 1, 2

• 100% sensitivity for detecting stroke when performed by trained practitioners (versus only 46% for early MRI) 1, 2
• Critical caveat: HINTS is unreliable when performed by non-experts—if you lack specific training, proceed directly to imaging for high-risk patients 2, 3
• Peripheral vertigo indicators: Normal head impulse test (abnormal is reassuring for peripheral), unidirectional horizontal nystagmus that lessens with visual fixation, no skew deviation 3
• Central vertigo red flags: Normal head impulse test, direction-changing nystagmus, vertical nystagmus, positive skew deviation 3

Complete Neurologic Examination

Perform a thorough neurologic exam on all dizzy patients to identify focal deficits suggesting central pathology. 1 Critical pitfall to avoid: 75-80% of patients with posterior circulation stroke causing acute vestibular syndrome have NO focal neurologic deficits initially, so a normal exam does not exclude stroke. 2, 3

Imaging Strategy

When NO Imaging Is Indicated

Do not order imaging for: 1, 2

• Brief episodic vertigo with typical BPPV features and positive Dix-Hallpike 1, 2
• Acute persistent vertigo with normal neurologic exam AND HINTS consistent with peripheral vertigo by a trained examiner 2
• Straightforward BPPV without atypical features 2

When MRI Brain Without Contrast Is Indicated

Order urgent MRI (NOT CT) for: 1, 2, 3

• 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, 2
• Focal neurological deficits, sudden hearing loss, inability to stand or walk 2
• Downbeating nystagmus or other central nystagmus patterns 2
• New severe headache accompanying dizziness 2
• Progressive symptoms suggesting mass lesion 2

Why CT Is Inadequate

CT head has very low diagnostic yield (<1%) for isolated dizziness and only 20-40% sensitivity for detecting causative pathology, particularly posterior circulation infarcts. 2 CT misses many posterior circulation strokes that are the most common central cause of acute dizziness. 2 MRI with diffusion-weighted imaging has significantly higher diagnostic yield (4% in isolated dizziness, up to 16% when changing diagnosis). 2, 5

Additional Imaging Considerations

• MRI head and internal auditory canal with contrast: For unilateral or pulsatile tinnitus, asymmetric hearing loss (to exclude vestibular schwannoma) 1, 2
• MRA head and neck: For suspected vertebrobasilar insufficiency in episodic vertigo 3
• CT temporal bone: For suspected structural inner ear pathology with auditory symptoms 3

Treatment Approach

For BPPV (Triggered Episodic Vertigo)

Perform canalith repositioning procedures (Epley maneuver) as first-line treatment immediately after diagnosis. 1, 2 This achieves 80% success after 1-3 treatments and 90-98% success with repeat maneuvers. 4, 1, 2

• Do NOT prescribe medications for typical BPPV—they are unnecessary and delay definitive treatment 2, 3
• Meclizine is FDA-approved for vertigo associated with vestibular system diseases but should be reserved for acute vestibular syndrome, not BPPV 6
• Reassess within one month to document resolution or persistence 2
• Counsel patients about 10-18% recurrence risk at one year and fall prevention strategies 1

For Persistent BPPV After Initial Treatment

If symptoms persist after initial canalith repositioning: 4

• Repeat Dix-Hallpike test to confirm persistent BPPV 4
• Perform additional repositioning maneuvers—success rate reaches 90-98% with repeat treatments 4, 1
• Consider vestibular rehabilitation therapy if balance and motion tolerance do not improve despite repositioning 2
• Reevaluate for coexisting vestibular conditions or CNS disorders that may simulate BPPV (found in 3% of treatment failures) 4, 3

For Acute Vestibular Syndrome (Peripheral Causes)

For vestibular neuritis or labyrinthitis after stroke is excluded: 6, 7

• Meclizine 25-100 mg daily in divided doses for symptom control 6
• Vestibular rehabilitation therapy as primary intervention for persistent symptoms 2
• Avoid prolonged vestibular suppressant use as it delays central compensation 7

Common Pitfalls to Avoid

• Relying on patient's description of "spinning" versus "lightheadedness"—focus on timing and triggers instead 2, 3
• Assuming normal neurologic exam excludes stroke—75-80% of posterior circulation strokes have no focal deficits initially 2, 3
• Ordering imaging for straightforward BPPV—this delays treatment and has low yield 1, 2
• Using CT instead of MRI when stroke is suspected—CT misses most posterior circulation infarcts 2, 5
• Failing to perform Dix-Hallpike when indicated—this is the gold standard for BPPV diagnosis 1, 3
• Prescribing medications for BPPV instead of performing repositioning maneuvers—this delays definitive treatment 2, 3
• Performing Dix-Hallpike when Romberg is positive—positive Romberg indicates central pathology requiring imaging first 3
• Trusting HINTS examination results from non-experts—reliability drops significantly without specific training 2, 3