HPI Pointers for Vertigo Workup in Hospital Setting
First Critical Distinction: Define the Symptom Type
Your initial task is to determine if the patient has true vertigo (sensation of spinning or rotational movement) versus vague dizziness, lightheadedness, or presyncope. 1
- True vertigo = spinning sensation is specific for inner ear dysfunction 1
- Feeling like fainting or passing out = presyncope, NOT vertigo 1
- Unsteady or off-balance without spinning = dizziness, not true vertigo 1
- Do not rely on the patient's vague description of "dizziness"—focus instead on timing, triggers, and associated symptoms 2
Essential Timing Questions (Most Diagnostically Valuable)
Duration of episodes is the single most important feature that distinguishes causes: 1
- Seconds only (<1 minute) = BPPV (benign positional vertigo) 1, 2
- Minutes duration = possible stroke/TIA or vestibular migraine 1, 2
- Hours = Ménière's disease or vestibular migraine 3
- Days to weeks (constant) = vestibular neuritis, labyrinthitis, or stroke 2, 3
Triggering Factors to Document
- Head position changes (rolling over in bed, looking up, bending down) strongly suggest BPPV 1, 2
- Pressure changes (coughing, sneezing, straining) suggest superior canal dehiscence or perilymph fistula 2
- No specific trigger with spontaneous onset suggests vestibular neuritis or central causes 2
Associated Symptoms (Critical for Differential)
Auditory symptoms:
- Hearing loss, tinnitus, or aural fullness = Ménière's disease or labyrinthitis 2, 3
- Sudden unilateral hearing loss = labyrinthitis or stroke (red flag requiring urgent evaluation) 2, 3
- Pulsatile tinnitus = vascular malformation or dissection (requires CTA) 2
Neurological symptoms (RED FLAGS):
- Dysarthria, dysphagia, visual blurring, drop attacks, limb weakness/numbness = posterior circulation stroke until proven otherwise 3
- New severe headache = mandates immediate imaging and neurologic consultation 2
- Focal neurological deficits = central cause requiring urgent MRI 2, 3
Migraine features:
- Headache, photophobia, phonophobia suggest vestibular migraine 2
- History of migraine headaches is relevant (34% of BPPV patients have migraine history) 1
Nystagmus Characteristics to Document
Peripheral (benign) patterns:
- Horizontal or rotatory nystagmus that lessens with visual fixation 1
- Latency of 5-20 seconds before onset, resolves within 60 seconds 2
Central (dangerous) patterns requiring immediate imaging:
- Direction-changing nystagmus without head position changes 2, 3
- Downbeating nystagmus 1, 2, 3
- Gaze-holding, direction-switching nystagmus 1
- Nystagmus that does NOT lessen with visual fixation 4
Vascular Risk Factors to Assess
- Age >50, hypertension, diabetes, hyperlipidemia, smoking, atrial fibrillation 1, 2
- High vascular risk patients with acute vestibular syndrome require MRI even without focal deficits 2
Medication Review (Leading Reversible Cause)
Document all medications, particularly: 1, 2
- Antihypertensives (diuretics, β-blockers, calcium antagonists, ACE inhibitors, nitrates)
- Sedatives and anticonvulsants
- Psychotropic drugs (antipsychotics, tricyclic antidepressants, antihistamines)
Fall History and Functional Impact
- Previous falls (dizziness increases fall risk 12-fold in elderly) 1
- Fear of falling or unsteadiness 1
- Among elderly with BPPV, 75% had fallen within prior 3 months 1
Trauma History
- Head trauma can cause posttraumatic vertigo that persists chronically with vertigo, disequilibrium, tinnitus, and headache 2
Psychiatric Screening
- Anxiety, panic disorder, depression are common causes of chronic vestibular syndrome 2
Critical Pitfall to Avoid
Never assume absence of focal neurologic deficits rules out stroke—75-80% of patients with acute vestibular syndrome from posterior circulation infarct have NO focal neurologic deficits. 2, 3 This is why the HINTS examination (when performed by trained practitioners) has 100% sensitivity for detecting stroke versus early MRI at only 46% sensitivity. 2