What is the approach to evaluating and managing a patient with vertigo in the outpatient department (OPD)?

Approach to Vertigo in the Outpatient Department

The initial evaluation of vertigo in the OPD should categorize patients by timing and triggers—not symptom quality—into one of three vestibular syndromes (Acute Vestibular Syndrome, Triggered Episodic Vestibular Syndrome, or Spontaneous Episodic Vestibular Syndrome), as this framework directly guides targeted physical examination and distinguishes benign peripheral causes from dangerous central pathology like stroke. 1

Initial History: Critical Questions to Ask

Focus on these specific elements in order of priority:

• Duration of episodes: Seconds suggests BPPV; minutes to hours suggests vestibular migraine or Ménière's disease; days to weeks suggests vestibular neuritis or stroke 1, 2
• Triggers: Head position changes indicate BPPV; no triggers suggest vestibular neuritis or stroke 1
• Associated symptoms:
  • Hearing loss, tinnitus, aural fullness → Ménière's disease 1
  • Headache, photophobia, phonophobia → vestibular migraine 1
  • Focal neurologic deficits, diplopia, dysarthria, facial numbness, limb weakness → posterior circulation stroke 3
• Fall history: Ask about falls in past year, feeling unsteady, and worry about falling 4, 5

Classification into Vestibular Syndromes

1. Triggered Episodic Vestibular Syndrome

• Characteristics: Brief episodes lasting seconds to <1 minute triggered by head movements 1
• Physical examination: Perform Dix-Hallpike maneuver bilaterally (head turned 45° to one side, neck extended 20°, bringing patient from upright to supine with affected ear down) 4
• Positive test: Torsional, upbeating nystagmus with vertigo indicates posterior canal BPPV 4
• If horizontal or no nystagmus: Perform supine roll test to assess for lateral canal BPPV 4

2. Acute Vestibular Syndrome (AVS)

• Characteristics: Acute persistent vertigo lasting days to weeks with constant symptoms 1
• Critical examination: Perform HINTS (Head Impulse, Nystagmus, Test of Skew) examination 1, 6
  • Normal head impulse test (no corrective saccade) suggests central cause 3, 6
  • Bidirectional, vertical, direction-changing, or pure torsional nystagmus indicates central pathology 6
  • Skew deviation (vertical misalignment on alternate cover test) indicates central cause 6
• HINTS has 100% sensitivity for posterior circulation stroke when performed by trained practitioners, superior to early MRI (46% sensitivity) 1

3. Spontaneous Episodic Vestibular Syndrome

• Characteristics: Episodes lasting minutes to hours without positional triggers 1
• Diagnosis guided by associated symptoms: Migraine features suggest vestibular migraine; episodic hearing loss/tinnitus/fullness suggest Ménière's disease 1

Red Flags Requiring Immediate Imaging/Referral

Any of these findings mandate urgent MRI brain and neurology consultation:

• Focal neurological deficits (diplopia, dysarthria, facial numbness, limb weakness, sensory changes) 3
• Inability to stand or walk independently 3
• New severe headache accompanying dizziness 3
• Sudden unilateral hearing loss with vertigo 3
• Abnormal HINTS examination in acute vestibular syndrome 3
• Downbeating nystagmus or other central nystagmus patterns 3
• Normal head impulse test in patient with acute vertigo and nystagmus 3
• Unilateral or pulsatile tinnitus 3

Critical pitfall: 75-80% of patients with posterior circulation stroke have NO focal neurologic deficits on standard examination 3

Imaging Decisions

Do NOT order imaging for:

• Brief episodic vertigo with typical BPPV features and positive Dix-Hallpike 1, 5
• Acute persistent vertigo with normal neurologic exam and HINTS consistent with peripheral vertigo by trained examiner 1, 5

Order MRI brain (without contrast) for:

• Abnormal neurologic examination 1, 5
• HINTS examination suggesting central cause 1, 5
• High vascular risk patients with acute vestibular syndrome 1, 5
• Unilateral or pulsatile tinnitus 1, 5
• Asymmetric hearing loss 1, 5

Never use CT head instead of MRI when stroke is suspected—CT has very low yield (<1% diagnostic yield for isolated dizziness) and misses many posterior circulation infarcts 3

Assessment of Modifying Factors

Evaluate for factors that modify management:

• Comorbidities: Diabetes, hypertension, anxiety, migraine, history of stroke or head trauma 4
• CNS disorders: Multiple sclerosis, degenerative cervical spine disease 4
• Impaired mobility or balance: Use Get Up and Go test, Tinetti Balance Assessment, or Berg Balance Scale 4, 1
• Fall risk: Among elderly patients with undiagnosed BPPV, 75% had fallen within prior 3 months 4, 5
• Lack of home support: Important for safe discharge planning 4

Posttraumatic BPPV requires up to 67% repeated repositioning maneuvers versus 14% for nontraumatic BPPV 4

Management Based on Diagnosis

BPPV (Most Common Cause)

• Treat immediately with canalith repositioning procedure (Epley maneuver) for posterior canal BPPV 4, 1
• Success rate 90-98% with repositioning maneuvers 4, 1, 5
• Do NOT recommend postprocedural postural restrictions after canalith repositioning 4
• Do NOT routinely prescribe vestibular suppressants (antihistamines, benzodiazepines) 4
• Meclizine is FDA-approved for vertigo associated with vestibular system diseases but should not be routine first-line for BPPV 7

Treatment Failures

• Reassess within 1 month to document resolution or persistence 4
• If Dix-Hallpike still positive, repeat repositioning maneuvers (success reaches 90-98% with additional maneuvers) 4
• If no improvement after 2-3 repositioning attempts or associated auditory/neurological symptoms: Perform thorough neurological examination and MRI brain/posterior fossa 4
• 3% of BPPV treatment failures have undiagnosed CNS disorder 4

Vestibular Neuritis

• Vestibular rehabilitation may be offered 4
• Symptomatic treatment with vestibular suppressants only during acute phase 7

Other Diagnoses

• Vestibular migraine: Migraine prophylaxis and lifestyle modifications 1
• Ménière's disease: Salt restriction, diuretics; intratympanic dexamethasone or gentamicin for refractory cases 1
• Posterior circulation stroke: Activate stroke protocol immediately 1, 5

Patient Education and Follow-up

Counsel all patients regarding:

• Recurrence risk: 15% per year; 37-50% at 5 years 4
• Safety precautions: Sit or lie down immediately when dizzy; use assistive devices if balance affected; avoid driving during acute episodes 5
• Fall prevention: Home safety modifications, especially for elderly patients 4
• Importance of follow-up: Earlier recognition of recurrent BPPV allows earlier treatment 4

Common Pitfalls to Avoid

• Do NOT rely on patient's description of "spinning" versus "lightheadedness"—focus on timing and triggers instead 3
• Do NOT assume all positional vertigo is BPPV—central pathologies can mimic BPPV; apogeotropic horizontal nystagmus on supine roll test and isolated positional downbeat nystagmus are red flags 8
• Do NOT miss the opportunity to perform bedside testing—Dix-Hallpike and HINTS provide more diagnostic value than imaging in most cases 3
• Do NOT order routine imaging for isolated dizziness with typical peripheral features—diagnostic yield is extremely low 3