What is the appropriate workup for a 46-year-old female patient presenting with dizziness?

Workup for Dizziness in a 46-Year-Old Female

The workup should begin by categorizing dizziness based on timing and triggers—not the patient's subjective description—to classify it into one of four vestibular syndromes, followed by targeted physical examination with the Dix-Hallpike maneuver for triggered symptoms or HINTS examination for acute persistent symptoms, reserving imaging only for red flag features suggesting central pathology. 1

Initial History: Focus on Timing and Triggers

The most critical step is determining the temporal pattern and what provokes the symptoms 1, 2:

• Brief episodic (<1 minute): Seconds of vertigo triggered by head position changes suggests benign paroxysmal positional vertigo (BPPV) 1, 3
• Acute persistent (days to weeks): Constant dizziness lasting days suggests acute vestibular syndrome, requiring differentiation between peripheral versus central causes 1, 2
• Spontaneous episodic (minutes to hours): Recurrent episodes with headache, photophobia, or phonophobia suggest vestibular migraine 1, 3
• Chronic (weeks to months): Consider medication side effects (antihypertensives, sedatives, anticonvulsants, psychotropics), anxiety/panic disorder, or posttraumatic vertigo 1, 2

Key Associated Symptoms to Elicit

• Hearing loss, tinnitus, or aural fullness: Suggests Ménière's disease 1, 3
• Headache, diplopia, dysarthria, numbness, or weakness: Suggests central pathology requiring urgent evaluation 1, 3

Physical Examination: Targeted Bedside Tests

For All Patients

• Observe for spontaneous nystagmus: Central patterns (downbeating, direction-changing) are red flags 1, 3
• Complete neurologic examination: Including cranial nerves, cerebellar testing, and gait assessment 1, 3

For Triggered Episodic Symptoms (Suspected BPPV)

• Perform Dix-Hallpike maneuver: Diagnostic criteria include 5-20 second latency, torsional upbeating nystagmus toward the affected ear, and symptoms resolving within 60 seconds 1, 2
• If positive: No imaging or additional testing needed; proceed directly to Epley maneuver with 90-98% success rate 1, 2

For Acute Persistent Symptoms (Acute Vestibular Syndrome)

• HINTS examination (Head Impulse, Nystagmus, Test of Skew): When performed by trained practitioners, this has 100% sensitivity for detecting stroke—superior to early MRI (46% sensitivity) 1, 2
• Critical caveat: HINTS is less reliable when performed by non-experts 2

Imaging: Only When Red Flags Present

Imaging is NOT routinely indicated for most dizziness cases 1, 2. Order MRI brain without contrast (NOT CT) only when:

• Focal neurological deficits present 1, 3
• HINTS examination suggests central cause 1, 2
• High vascular risk patients (hypertension, atrial fibrillation) with acute vestibular syndrome 1, 2
• Sudden unilateral hearing loss 1, 3
• Inability to stand or walk 1, 3
• Downbeating or other central nystagmus patterns 1, 3
• New severe headache 2
• Progressive neurologic symptoms 1
• Unilateral or pulsatile tinnitus (to exclude vestibular schwannoma) 1, 2

Why MRI Over CT

• CT has very low diagnostic yield (<1%) for isolated dizziness and only 20-40% sensitivity for posterior circulation infarcts 2
• MRI with diffusion-weighted imaging has 4% diagnostic yield in isolated dizziness, with 70% of positive findings being ischemic stroke 1, 2

Laboratory Testing

Routine laboratory testing has extremely low yield in isolated dizziness with normal examination 3. Consider only:

• Bedside glucose testing if appropriate 3
• Medication review (a leading reversible cause of chronic dizziness) 1, 2

Common Pitfalls to Avoid

• Don't rely on patient descriptions of "spinning" versus "lightheadedness": Focus on timing and triggers instead 1, 2
• Don't assume normal neurologic exam excludes stroke: 75-80% of posterior circulation strokes have no focal deficits 2, 3
• Don't order imaging for straightforward BPPV with positive Dix-Hallpike: This delays treatment unnecessarily 1, 2
• Don't use CT when stroke is suspected: CT misses many posterior circulation infarcts 2
• Don't skip the Dix-Hallpike maneuver: It's the gold standard for BPPV diagnosis 1, 3

Treatment Based on Diagnosis

• BPPV: Canalith repositioning procedures (Epley maneuver) with 80% success after 1-3 treatments; counsel about 10-18% recurrence at 1 year 1, 2
• Vestibular migraine: Migraine prophylaxis and lifestyle modifications 1, 3
• Ménière's disease: Salt restriction, diuretics, consider intratympanic treatments 1
• Persistent symptoms after initial treatment: Vestibular rehabilitation therapy significantly improves gait stability 1, 2