What is the evaluation for vertigo (dizziness)?

From the Guidelines

Vertigo evaluation should begin with a thorough history and physical examination to distinguish between peripheral and central causes, starting with the Dix-Hallpike maneuver to assess for benign paroxysmal positional vertigo (BPPV), as recommended by the 2017 clinical practice guideline on BPPV 1. The evaluation process should prioritize the identification of BPPV, the most common cause of peripheral vertigo, as it can be effectively treated with bedside repositioning exercises, such as the Epley maneuver, which has a high success rate of around 80% with only 1-3 treatments 1. Additional bedside tests, including the head impulse test, evaluation for nystagmus, and test of skew (HINTS exam), can help differentiate peripheral from central causes with high sensitivity, as noted in the 2024 update on ACR appropriateness criteria for dizziness and ataxia 1. Key points to consider in the evaluation process include:

• The use of laboratory tests, such as complete blood count, metabolic panel, and thyroid function tests, to rule out underlying conditions that may be contributing to the vertigo
• The recommendation for audiometry in patients with hearing symptoms
• The indication for imaging studies, like MRI brain with contrast, when central causes are suspected, particularly with neurological symptoms, risk factors for stroke, or when symptoms persist despite treatment, as highlighted in the 2024 update 1
• The consideration of vestibular rehabilitation therapy early in the treatment process to promote central compensation and improve balance function
• The use of meclizine 12.5-25mg every 6 hours as needed for symptomatic relief during evaluation, but limiting its use to 3-5 days to prevent compensation delay. It is essential to note that the HINTS examination, when performed by specially trained practitioners, can be more sensitive than early MRI for detecting infarct, and its negative results may obviate the need for imaging in patients with isolated acute persistent vertigo, as discussed in the 2024 update 1.

From the FDA Drug Label

Meclizine hydrochloride tablets are indicated for the treatment of vertigo associated with diseases affecting the vestibular system in adults (1). Meclizine hydrochloride tablets are indicated for the treatment of vertigo associated with diseases affecting the vestibular system in adults. Meclizine hydrochloride tablets are indicated for the treatment of vertigo associated with diseases affecting the vestibular system in adults.

Vertigo Evaluation: Meclizine is indicated for the treatment of vertigo associated with diseases affecting the vestibular system in adults 2, 2, 2.

• The drug is used to treat vertigo, but the label does not provide information on how to evaluate vertigo.
• Key Point: The FDA drug label provides information on the treatment of vertigo, but not on the evaluation of vertigo.

From the Research

Vertigo Evaluation

• The evaluation of vertigo involves determining whether the patient has a peripheral or central cause of vertigo 3, 4.
• A thorough history and physical examination, including special tests such as the Dix-Hallpike maneuver, are essential in making this distinction 3, 4, 5.
• The HINTS (head-impulse, nystagmus, test of skew) examination can also help distinguish peripheral from central etiologies 4.
• Laboratory testing and imaging are not always required, but may be necessary in certain cases, such as when central etiologies are suspected 4, 6.

Diagnostic Procedures

• The diagnosis of vertigo has experienced a paradigm shift in recent years, with new diagnostic possibilities and modern vestibular test procedures 6.
• The video head impulse test and vestibular evoked myogenic potentials are examples of new diagnostic options that allow for a complex objective assessment of the vestibular organ 6.
• The Epley maneuver is a standard treatment for benign paroxysmal positional vertigo (BPPV), but its effectiveness in patients with multiple sclerosis has been poorly studied 7.

Clinical Presentations

• Benign paroxysmal positional vertigo, acute vestibular neuronitis, and Meniere's disease are common causes of vertigo 3, 4.
• Vertigo can also be a symptom of other conditions, such as cerebrovascular disease, migraine, psychological disease, perilymphatic fistulas, multiple sclerosis, and intracranial neoplasms 3.
• The clinical presentation of vertigo can vary, with patients experiencing episodic vertigo triggered by head motion, vertigo with unilateral hearing loss, or episodic vertigo not associated with any trigger 4.