What is the approach to a patient presenting with dizziness?

Approach to Dizziness

Categorize dizziness by timing and triggers—not by the patient's subjective description—to determine the specific vestibular syndrome, which directly guides your physical examination and management decisions. 1, 2

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:

• Acute Vestibular Syndrome (AVS): Acute persistent dizziness lasting days to weeks with constant symptoms 1, 2
• Triggered Episodic Vestibular Syndrome: Brief episodes triggered by head position changes (typically BPPV) 1, 2
• Spontaneous Episodic Vestibular Syndrome: Recurrent episodes without positional triggers (vestibular migraine, Menière disease) 1, 2
• Chronic Vestibular Syndrome: Persistent disequilibrium lasting months 1, 2

Critical History Elements

Focus on these specific details rather than vague symptom descriptions 1, 2:

• Duration and onset: Seconds (BPPV), minutes to hours (Menière, migraine), days to weeks (vestibular neuritis vs. stroke) 1, 2
• Positional triggers: Head movements triggering symptoms suggest BPPV 1, 2
• Associated symptoms:
  • Hearing loss or tinnitus suggests Menière disease 1, 2
  • Headache, diplopia, dysarthria, numbness, or weakness indicate central causes requiring urgent evaluation 1, 2

Essential Physical Examination

For All Patients

• Observe for spontaneous nystagmus at rest and with gaze 1, 2
• Complete neurologic examination including cranial nerves, cerebellar testing, and gait assessment 2
• Orthostatic vital signs to exclude cardiovascular causes 2

Syndrome-Specific Testing

For Triggered Episodic Vestibular Syndrome (suspected BPPV):

• Perform Dix-Hallpike maneuver: Positive findings include 5-20 second latency, torsional upbeating nystagmus toward the affected ear, symptoms resolving within 60 seconds 1, 2
• Supine roll test for horizontal canal BPPV 1, 2

For Acute Vestibular Syndrome (AVS):

• HINTS examination (Head Impulse, Nystagmus, Test of Skew) if you are trained in this technique 1, 2
• HINTS has 100% sensitivity for posterior circulation stroke when performed by trained practitioners, superior to early MRI (46% sensitivity) 2
• Critical pitfall: 75-80% of patients with posterior circulation stroke have NO focal neurologic deficits on standard examination 2, 3

Imaging Decisions

Do NOT Image

• Typical BPPV with positive Dix-Hallpike testing 1, 2
• Isolated dizziness with clear peripheral features and normal neurologic exam (diagnostic yield only 4%) 1, 3

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

• Acute vestibular syndrome with abnormal neurologic examination 1, 2
• Abnormal HINTS examination suggesting central cause 1, 2
• High vascular risk patients (hypertension, atrial fibrillation) with acute vestibular syndrome, even with normal neurologic exam 1, 3
• Unilateral or pulsatile tinnitus to exclude cerebellopontine angle tumors 1, 2
• Asymmetric hearing loss to exclude vestibular schwannoma 1, 2
• Inability to stand or walk independently 3
• New severe headache accompanying dizziness 3
• Downbeating nystagmus or other central nystagmus patterns 3

Never use CT head for stroke evaluation in dizziness—CT misses many posterior circulation infarcts with sensitivity of only 20-40%, whereas MRI with diffusion-weighted imaging is the appropriate study 3

Red Flags Requiring Urgent Evaluation

These findings mandate immediate imaging and neurologic consultation 3:

• Focal neurological deficits: Diplopia, dysarthria, facial numbness, limb weakness, sensory changes 3
• Sudden unilateral hearing loss with vertigo 3
• New severe headache 3
• Inability to stand or walk 3
• Loss of consciousness (never a symptom of peripheral vestibular disorders) 3
• Normal head impulse test in a patient with acute vertigo and nystagmus (suggests central cause) 3

Treatment Based on Diagnosis

BPPV

• Canalith repositioning procedures (Epley maneuver) as first-line treatment with 90-98% success rate 1, 2
• Counsel patients about 10-18% recurrence risk at 1 year, up to 36% long-term 1, 2
• Address fall prevention, particularly in elderly patients 1, 2

Menière Disease

• Salt restriction and diuretics 2
• Consider intratympanic treatments for refractory cases 2

Vestibular Migraine

• Migraine prophylaxis and lifestyle modifications 2

Vestibular Neuritis

• Vestibular suppressant medications (short-term only) and vestibular rehabilitation 2

Common Pitfalls to Avoid

• Do not rely on symptom quality ("spinning" vs. "lightheadedness")—timing and triggers are more reliable 2, 3
• Do not assume normal neurologic exam excludes stroke in AVS—most posterior circulation strokes lack focal deficits 2, 3
• Do not overuse imaging in patients with clear peripheral causes 1, 3
• Do not fail to perform Dix-Hallpike when BPPV is suspected—it provides more diagnostic value than imaging 3
• Do not use CT instead of MRI for suspected stroke 3