What is the initial management for a patient presenting with dizziness and nausea?

Initial Management of a 27-Year-Old with Dizziness and Nausea

The initial management prioritizes distinguishing peripheral from central causes through targeted history-taking focused on timing and triggers, followed by the Dix-Hallpike maneuver for benign paroxysmal positional vertigo (BPPV) and HINTS examination if acute vestibular syndrome is present, while avoiding unnecessary imaging in patients with normal neurologic examinations. 1

Step 1: Characterize the Timing and Triggers (Not the Quality)

The most critical initial step is determining whether symptoms are triggered episodic (lasting seconds to minutes with specific head movements), spontaneous episodic (lasting minutes to hours without triggers), or acute persistent (continuous for days). 1, 2

• Triggered episodic vertigo lasting <1 minute with position changes strongly suggests BPPV, the most common cause of peripheral vertigo. 1
• Spontaneous episodic vertigo with unilateral hearing loss suggests Ménière's disease, while episodes without hearing loss may indicate vestibular migraine. 1, 2
• Acute persistent vertigo (acute vestibular syndrome) with nausea, vomiting, and head-motion intolerance requires urgent differentiation between benign vestibular neuritis and life-threatening posterior circulation stroke. 1

Critical pitfall: Do not rely on patient descriptors like "spinning" versus "lightheadedness"—these are inconsistent and clinically unhelpful. 1, 2

Step 2: Perform Targeted Physical Examination

For Triggered Episodic Symptoms (Suspected BPPV)

Perform the Dix-Hallpike maneuver bilaterally to diagnose posterior canal BPPV. 1

• Rotate the patient's head 45 degrees to one side, then rapidly move them from sitting to supine with the head extended 20 degrees below horizontal. 1
• Positive test: Upbeating-torsional nystagmus with latency of 1-5 seconds, lasting <60 seconds, accompanied by vertigo. 1
• The test must be performed on both sides to determine which ear is affected. 1
• If positive with typical findings, no imaging is needed—proceed directly to canalith repositioning (Epley maneuver). 1

Contraindications to Dix-Hallpike: Severe cervical stenosis, vertebrobasilar disease risk, severe rheumatoid arthritis, Down syndrome, or morbid obesity (may require assistance or tilt table). 1

For Acute Persistent Vertigo (Acute Vestibular Syndrome)

Perform the HINTS examination (Head Impulse, Nystagmus, Test of Skew) to distinguish peripheral from central causes. 1, 3, 2

• Head Impulse Test: Abnormal (corrective saccade) suggests peripheral; normal suggests central stroke. 3, 2
• Nystagmus: Unidirectional horizontal nystagmus suggests peripheral; direction-changing or vertical nystagmus suggests central. 3, 2
• Test of Skew: Vertical misalignment suggests central pathology. 3, 2

Any central features on HINTS require urgent MRI with diffusion-weighted imaging, as CT misses up to 50% of posterior circulation strokes in the first 48 hours. 1

Additional Examination Elements

• Orthostatic vital signs: Measure blood pressure and heart rate supine, then at 3,5, and 10 minutes standing to assess for orthostatic hypotension or postural orthostatic tachycardia syndrome (POTS). 4
• Neurologic examination: Assess for focal deficits, ataxia, dysarthria, or altered consciousness that would indicate central pathology requiring urgent imaging. 1

Step 3: Determine Need for Imaging

Imaging is NOT indicated for:

• Typical BPPV with positive Dix-Hallpike and no neurologic deficits. 1
• Peripheral vestibular syndrome with reassuring HINTS examination and no focal neurologic signs. 1, 2

MRI brain with and without contrast IS indicated for:

• Any abnormal HINTS findings suggesting central pathology. 1
• Focal neurologic deficits accompanying dizziness. 1
• Acute persistent vertigo in high vascular risk patients (age >50, diabetes, hypertension, prior stroke). 1
• Atypical BPPV features: central positional nystagmus, prolonged symptoms, or failure to respond to repositioning maneuvers. 1

Critical pitfall: CT head has extremely low yield (<1%) in dizzy patients with normal neurologic examinations and misses most posterior circulation strokes. 1, 2

Step 4: Initiate Symptomatic Treatment

For Nausea and Vomiting

Use prokinetic antiemetics as first-line adjunct therapy: metoclopramide 10 mg or domperidone (if available) for nausea associated with vestibular disorders. 1

• If metoclopramide alone is insufficient, add ondansetron 4-8 mg every 8 hours for synergistic effect through different receptor mechanisms (dopamine D2 plus serotonin 5-HT3 blockade). 5
• Switch to scheduled around-the-clock dosing rather than PRN if symptoms are persistent. 5
• If oral route is not feasible due to severe vomiting, use intravenous or rectal administration. 1, 5

Avoid opioids and barbiturates—they have questionable efficacy for vestibular symptoms and carry significant risks of dependency and sedation. 1

For Acute Vestibular Neuritis

Vestibular suppressants (meclizine 25 mg three times daily or dimenhydrinate 50 mg every 6 hours) provide short-term symptom relief but should be limited to 2-3 days to avoid delaying central compensation. 2

Step 5: Rule Out Red Flags Requiring Urgent Intervention

Red flags mandating immediate evaluation for secondary causes:

• New headache at age >50 (consider temporal arteritis). 1
• Headache with fever and neck stiffness (meningitis or subarachnoid hemorrhage). 1
• Focal neurologic symptoms, altered consciousness, or personality changes (intracranial mass or stroke). 1
• Severe hypertension (>180/120) with nausea—may indicate hypertensive emergency requiring IV antihypertensives. 5

For persistent nausea, check for reversible causes before escalating therapy:

• Review medications for constipating or nauseating agents (opioids cause nausea in 50% of patients). 5, 6
• Check serum calcium to exclude hypercalcemia. 5, 6
• Assess for constipation or bowel obstruction through examination and imaging if indicated. 5, 6

Practical Algorithm Summary

1. Characterize timing: Triggered episodic (<1 min) → perform Dix-Hallpike for BPPV. 1
2. If Dix-Hallpike positive with typical findings: Treat with Epley maneuver; no imaging needed. 1
3. If acute persistent vertigo: Perform HINTS examination. 1, 3
4. If HINTS suggests central pathology or high vascular risk: Urgent MRI brain. 1
5. If HINTS suggests peripheral and no red flags: Treat symptomatically with antiemetics and vestibular suppressants (limited duration). 1, 5, 2
6. For nausea: Start metoclopramide; add ondansetron if insufficient; rule out reversible causes. 1, 5
7. Check orthostatic vitals if symptoms worsen with prolonged standing. 4