What is the best initial approach to manage a 40-year-old woman with persistent dizziness and vertigo, no history of cancer or stroke, and without training in Head Impulse, Nystagmus, and Test of Skew (HINTS)?

Initial Management of Persistent Dizziness/Vertigo Without HINTS Training

In a 40-year-old woman with persistent dizziness and vertigo, no stroke/cancer history, and no access to HINTS-trained practitioners, obtain MRI brain without contrast to exclude posterior circulation stroke, as up to 25% of acute vestibular syndrome cases are due to stroke and 75-80% lack focal neurologic deficits. 1, 2

Immediate Clinical Assessment

Critical History Elements to Obtain

• Determine the exact nature of symptoms: Ask specifically if she experiences true spinning/rotation (vertigo) versus vague dizziness, as true vertigo indicates vestibular pathology 1
• Establish timing pattern: Determine if symptoms are continuous (suggesting vestibular neuritis, labyrinthitis, or stroke) versus episodic (suggesting BPPV, Ménière's, or vestibular migraine) 1, 3
• Duration of episodes: Seconds suggest BPPV, minutes to hours suggest vestibular migraine or Ménière's, continuous >24 hours suggests vestibular neuritis or stroke 1, 4
• Identify triggers: Positional triggers (rolling over, looking up) strongly suggest BPPV, while spontaneous onset raises concern for central causes 1
• Screen for auditory symptoms: Hearing loss, tinnitus, or aural fullness strongly favor peripheral causes like Ménière's disease or labyrinthitis 1, 2

Physical Examination Priorities

• Assess for focal neurologic deficits: Check for diplopia, dysphagia, dysarthria, limb weakness, or sensory changes—any of these mandate urgent neuroimaging 2, 3
• Evaluate nystagmus pattern: Horizontal or horizontal-rotatory nystagmus suggests peripheral cause; pure vertical or direction-changing nystagmus indicates central pathology 2
• Test gait and balance: Severe imbalance out of proportion to vertigo suggests cerebellar involvement requiring imaging 2
• Perform Dix-Hallpike maneuver: If episodic positional symptoms are present, this can diagnose BPPV without requiring HINTS expertise 1

Risk Stratification for Imaging

High-Risk Features Requiring MRI Brain Without Contrast

• Age >50 years with vascular risk factors (hypertension, diabetes, atrial fibrillation, smoking) 1, 2
• Continuous vertigo lasting >24 hours (acute vestibular syndrome) even without focal deficits, as 11-25% have posterior circulation stroke 1
• Any focal neurologic symptoms or signs 2, 3
• Severe postural instability or inability to walk 3
• Pure vertical or direction-changing nystagmus 2
• Severe headache accompanying vertigo 3

Lower-Risk Scenarios Where Imaging May Be Deferred

• Brief episodic vertigo (<1 minute) triggered by head movements with typical nystagmus on Dix-Hallpike: This is BPPV and requires no imaging 1
• Young patient with recurrent vertigo plus unilateral hearing loss/tinnitus: Consider Ménière's disease, but MRI brain and internal auditory canal with contrast is still recommended to exclude vestibular schwannoma 1

Initial Management Algorithm

If BPPV is Suspected (Episodic, Positional, <1 Minute)

• Perform Dix-Hallpike maneuver: Positive test confirms diagnosis 1
• Treat with Epley maneuver (canalith repositioning procedure): Success rate 90-98% with repeated maneuvers 1, 5
• No imaging required unless atypical features present (lack of nystagmus, treatment failure after multiple attempts) 1

If Acute Vestibular Syndrome (Continuous Vertigo >24 Hours)

• Order MRI brain without contrast urgently: This is the preferred imaging modality with superior sensitivity for posterior circulation stroke compared to CT 1
• CT head without contrast is acceptable if MRI unavailable or contraindicated, though less sensitive (may miss up to 11% of strokes initially) 1
• Do not rely on normal neurologic examination to exclude stroke: 75-80% of posterior circulation infarcts lack focal deficits initially 1, 2

Symptomatic Treatment While Awaiting Diagnosis

• Meclizine 25-50mg orally is FDA-approved for vertigo associated with vestibular system diseases 6
• Limit vestibular suppressants to acute phase only (<72 hours), as prolonged use impairs central compensation 7
• Initiate vestibular rehabilitation once acute phase resolves, as this benefits most peripheral and many central causes 7

Common Pitfalls to Avoid

• Do not assume normal neurologic exam excludes stroke: This is the most dangerous error, as the majority of posterior circulation strokes present without focal deficits 1, 2
• Do not order imaging for typical BPPV: This wastes resources and delays appropriate treatment with repositioning maneuvers 1
• Do not use CT as definitive rule-out for stroke in acute vestibular syndrome: CT misses up to 11% of posterior circulation infarcts; MRI is required 1
• Do not continue vestibular suppressants long-term: This prevents central compensation and prolongs disability 7

When Specialist Referral is Indicated

• Persistent symptoms after appropriate initial treatment: Requires reevaluation for treatment failure, coexisting conditions, or missed central pathology 1
• Recurrent vertigo with hearing loss: Needs ENT evaluation for possible Ménière's disease or vestibular schwannoma 1
• Any imaging abnormality: Requires neurology consultation 1
• Refractory BPPV after multiple repositioning attempts: May need surgical intervention (>96% success rate with canal plugging) 1