What is the initial approach for a 40-year-old woman with persistent dizziness and vertigo, but no nystagmus, and without a history of cancer or stroke?

Initial Approach for Persistent Dizziness/Vertigo Without Nystagmus in a 40-Year-Old Woman

In a 40-year-old woman with persistent dizziness and vertigo but no nystagmus on examination and no history of cancer or stroke, the absence of nystagmus significantly narrows the differential and requires careful consideration of non-vestibular causes, atypical presentations of vestibular disorders, or central pathology that may not manifest typical eye findings. 1

Critical First Steps in Evaluation

Clarify the Symptom Pattern

• Determine if this is true vertigo (sensation of rotation/spinning) versus non-specific dizziness (disturbed spatial orientation without false motion sense), as many patients use "dizziness" vaguely to describe lightheadedness or presyncope, which are not vestibular in origin 2, 1
• Document the exact duration of symptoms: seconds suggest BPPV, minutes to hours suggest vestibular migraine or Ménière's disease, days to weeks suggest vestibular neuritis or central pathology 1
• Identify specific triggers: positional changes, head movements, or spontaneous onset 1
• Ask about associated symptoms: hearing loss, tinnitus, aural fullness (Ménière's disease), headache with photophobia/phonophobia (vestibular migraine), or neurological symptoms (stroke/TIA) 2, 1

The Absence of Nystagmus: Key Implications

The lack of nystagmus is atypical for most acute vestibular disorders and raises several important considerations:

• Vestibular neuritis and labyrinthitis typically present with prominent unidirectional horizontal nystagmus, so its absence makes these diagnoses less likely 2
• BPPV should produce characteristic positional nystagmus on Dix-Hallpike testing; absence of nystagmus despite symptoms suggests either the test was not performed correctly, symptoms have resolved between episodes, or an alternative diagnosis 1
• Approximately 75-80% of patients with posterior circulation stroke from acute vestibular syndrome have no focal neurologic deficits, and some may have subtle or absent nystagmus, making this a critical consideration 2, 1

Physical Examination Priorities

Perform Targeted Vestibular Testing

• Execute the Dix-Hallpike maneuver bilaterally to assess for BPPV, looking for latency of 5-20 seconds, torsional upbeating nystagmus toward the affected ear, and symptoms that crescendo then resolve within 60 seconds 1, 3
• Perform the supine roll test for lateral canal BPPV 4
• If symptoms are acute and persistent (days), perform the HINTS examination (Head Impulse, Nystagmus, Test of Skew) if you are trained in this technique, as it has 100% sensitivity for detecting posterior circulation stroke when performed by experts 1

Screen for Central Pathology Red Flags

Look specifically for these warning signs that mandate urgent neuroimaging: 1, 3

• Nystagmus that changes direction without changes in head position
• Downward-beating nystagmus (especially in Dix-Hallpike)
• Inability to stand or walk (severe truncal ataxia)
• Any focal neurological deficits
• New severe headache accompanying dizziness
• Sudden unilateral hearing loss

Complete Neurological and Cardiovascular Assessment

• Assess gait and balance to detect truncal ataxia suggesting cerebellar pathology 3
• Measure orthostatic vital signs to exclude orthostatic hypotension 5
• Perform a thorough otologic examination looking for signs of infection, effusion, or structural abnormalities 2

Differential Diagnosis Without Nystagmus

Most Likely Etiologies in This Clinical Context

Vestibular migraine is a leading consideration, with prevalence of 3.2% and representing up to 14% of vertigo cases, often presenting with attacks lasting hours but variable duration, and may not always show nystagmus between episodes 3, 2

Medication-induced dizziness is a leading reversible cause of chronic vestibular symptoms; review antihypertensives, sedatives, anticonvulsants, and psychotropic drugs 1

Anxiety or panic disorder commonly causes chronic dizziness without objective vestibular findings and should be screened for with psychiatric symptom assessment 1

Ménière's disease may present between acute attacks without nystagmus, but should have associated fluctuating hearing loss, tinnitus, or aural fullness 2, 1

Central pathology (posterior fossa mass, cerebellar stroke) must be considered, as approximately 10% of cerebellar strokes present similarly to peripheral vestibular processes, and 3% of patients with failed BPPV treatment have underlying CNS disorders 3, 4

Imaging Decision Algorithm

When NOT to Image

No imaging is indicated if: 2, 1

• Brief episodic positional vertigo with typical BPPV features on Dix-Hallpike testing
• Acute persistent vertigo with normal neurologic exam AND HINTS examination consistent with peripheral vertigo (when performed by trained examiner)
• Clear diagnosis of vestibular migraine with typical features and no red flags

When to Obtain MRI Brain Without Contrast

MRI brain without contrast is recommended for: 2, 1

• Persistent symptoms without clear diagnosis after appropriate vestibular testing
• Any red flag features (focal neurologic deficits, severe truncal ataxia, inability to walk, new severe headache)
• Unilateral or pulsatile tinnitus
• Asymmetric hearing loss
• High vascular risk patients with acute vestibular syndrome
• Failure to respond to appropriate vestibular treatments after 2-3 attempts
• Atypical nystagmus patterns suggesting central pathology

Common Pitfall: CT head has very low diagnostic yield (<1%) for isolated dizziness and misses many posterior circulation infarcts; MRI with diffusion-weighted imaging is far superior (4-16% diagnostic yield) 1

Initial Management Approach

If BPPV is Confirmed Despite Absent Nystagmus

• Perform canalith repositioning procedures (Epley maneuver) as first-line treatment, with 80% success after 1-3 treatments and 90-98% after repeat maneuvers 1, 4
• No medications are needed for typical BPPV 1

If Vestibular Migraine is Suspected

• Initiate migraine prophylaxis and lifestyle modifications 2, 3
• Consider consultation with neurology for refractory cases

If No Clear Diagnosis After Initial Evaluation

• Review all medications and consider discontinuation or dose reduction of vestibulotoxic agents 1
• Screen for psychiatric comorbidities (anxiety, panic disorder, depression) and treat appropriately 1
• Consider vestibular rehabilitation therapy for persistent symptoms, which significantly improves gait stability and is particularly beneficial for patients with chronic symptoms 1, 4
• Obtain MRI brain without contrast to exclude structural pathology 1

Symptomatic Treatment Considerations

Meclizine is FDA-approved for treatment of vertigo associated with vestibular system diseases 6, but pharmacologic intervention should be limited as it often impairs central nervous system compensation for dizziness 5

Critical Pitfalls to Avoid

Do not assume normal neurologic exam excludes stroke: 75-80% of patients with acute vestibular syndrome from posterior circulation infarct have no focal neurologic deficits 2, 1

Do not rely solely on patient's description of "spinning" versus "lightheadedness": focus instead on timing, triggers, and associated symptoms 1

Do not order CT when stroke is suspected: CT misses many posterior circulation infarcts and should not substitute for MRI 1

Do not assume absence of nystagmus rules out vestibular pathology: symptoms may be between episodes, or central pathology may present atypically 3, 4

Do not miss the 1-month reassessment window: patients should be reevaluated within one month to document resolution or persistence and adjust management accordingly 1, 4