What to do when all diagnostic tests are negative for a patient with persistent symptoms like dizziness or vertigo?

Management of Persistent Dizziness/Vertigo with Negative Diagnostic Tests

When all diagnostic tests are negative in a patient with persistent dizziness or vertigo, initiate vestibular rehabilitation therapy immediately while reassessing for psychiatric and functional vestibular disorders, particularly Persistent Postural-Perceptual Dizziness (PPPD), which is the most common diagnosis in chronic vestibular syndrome when standard testing is unrevealing. 1, 2

Immediate Clinical Actions

Reassess the Diagnosis

• Perform a structured timing-and-triggers assessment to classify symptoms as acute vestibular syndrome (AVS), episodic vestibular syndrome (EVS), or chronic vestibular syndrome (CVS) 3
• If symptoms are chronic (lasting >3 months), PPPD and psychogenic dizziness account for 54.5% of CVS cases in neurological practice 2
• Re-examine for BPPV using proper technique: Dix-Hallpike maneuver for posterior canal and supine roll test for lateral canal, as BPPV is the most common missed diagnosis (35% of all vertigo cases) 4

Consider Overlooked Vestibular Disorders

• Evaluate for Ménière's disease criteria: Two or more spontaneous vertigo attacks lasting 20 minutes to 12 hours, with fluctuating low-to-mid frequency hearing loss, tinnitus, or aural fullness 4
• Assess for vestibular migraine (VM): More prevalent in women (10.7% vs general population), often presents with episodic symptoms 2
• Screen for bilateral vestibulopathy: Abnormal VOR gain on rotatory chair testing indicates bilateral vestibular dysfunction requiring specialized management 1

Primary Treatment Strategy

Initiate Vestibular Rehabilitation

Begin vestibular rehabilitation therapy immediately, as this is the cornerstone of treatment for persistent vestibular symptoms regardless of specific etiology 1, 5:

• Habituation exercises to reduce symptom provocation 1
• Adaptation exercises for gaze stabilization 1
• Balance training to reduce fall risk 1
• Can be self-administered or clinician-supervised 4

Avoid Common Pitfalls

Do not prescribe vestibular suppressant medications (antihistamines, benzodiazepines, meclizine) for chronic symptoms 4, 1, 5:

• These medications delay central vestibular compensation 1, 5
• Meclizine is FDA-approved only for acute vertigo associated with vestibular system diseases, not chronic management 6
• Side effects include drowsiness and anticholinergic effects that worsen functional status 6

Systematic Evaluation for Modifying Factors

Assess Risk Factors Using P-SCHEME 5

• Pain conditions affecting mobility
• Shoes (inappropriate footwear)
• Cognitive impairment
• Hypotension (orthostatic)
• Eyesight problems
• Medications (polypharmacy, CNS depressants)
• Environmental hazards

Evaluate Fall Risk

• Perform Timed Up and Go (TUG) test: >12 seconds indicates increased fall risk requiring comprehensive intervention 5
• Berg Balance Scale: Score <41 indicates need for assistive device 5
• Implement fall prevention strategies immediately if risk identified 1

When to Pursue Additional Testing

Red Flags Requiring Imaging 4

Obtain MRI brain only if any of these are present:

• Severe headache with neurological signs
• Abnormal cranial nerve findings
• Visual disturbances beyond nystagmus
• Cerebellar signs (ataxia, dysmetria)
• Progressive symptoms despite treatment
• New focal neurological deficits

Consider Repeat Vestibular Testing 1, 5

Order vestibular function testing if:

• Symptoms persist after 1 month of treatment 4, 1
• Suspicion for progression of vestibular dysfunction 1, 5
• Multiple concurrent vestibular disorders suspected 4, 1
• Nystagmus findings are equivocal or unusual 4

Specific Diagnostic Considerations

Spontaneous Intracranial Hypotension

Consider this rare diagnosis if 4:

• Non-orthostatic holocephalic headaches
• MRI shows diffuse dural/leptomeningeal enhancement
• Symptoms include dizziness with nausea
• Standard vestibular testing negative

Psychiatric and Functional Disorders

Screen systematically for 2:

• PPPD: Persistent non-spinning dizziness lasting ≥3 months, worse with upright posture and visual motion
• Psychogenic dizziness: Accounts for 18.9% of CVS cases 2
• Anxiety and depression comorbidities

Follow-Up Protocol

Mandatory Reassessment Timeline

Reevaluate within 1 month after initiating treatment 4, 1, 5:

• Document resolution or persistence of symptoms
• Assess treatment adherence and technique
• Modify rehabilitation program if inadequate response 1

If Symptoms Persist

Systematically evaluate for 4, 1:

• Unresolved BPPV (repeat positional testing)
• Underlying peripheral vestibular disorders
• Central nervous system disorders
• Need for specialty referral to neurotology or vestibular rehabilitation specialist

Patient Education Priorities

Counsel patients on 4:

• Impact on safety, particularly fall risk and driving restrictions
• Potential for disease recurrence (BPPV recurs in 15-50% within 5 years)
• Importance of continuing vestibular exercises even after symptom improvement
• Expected timeline for central compensation (typically 6-12 weeks)

Key Clinical Pearls

• Negative testing does not mean absence of vestibular pathology—many vestibular disorders have normal imaging and standard vestibular tests 1, 2
• Discordance between tests is common, particularly in Ménière's disease where caloric testing may be abnormal while other tests are normal 1
• Multiple concurrent vestibular disorders occur frequently—don't stop at one diagnosis 4, 1
• Central compensation takes time—symptoms may persist 6-12 weeks even with appropriate treatment 1