Approach to a 22-Year-Old with Dizziness
In a 22-year-old with dizziness, immediately categorize the symptom by timing and triggers—not by vague descriptors like "spinning" versus "lightheadedness"—to determine if this represents brief episodic vertigo (seconds, suggesting BPPV), acute persistent vertigo (days, suggesting vestibular neuritis or stroke), spontaneous episodic vertigo (minutes to hours, suggesting vestibular migraine), or chronic dizziness (weeks to months, suggesting medication effects or psychiatric causes). 1, 2
Initial History: Focus on Timing and Triggers
The most diagnostically valuable information comes from precise timing and specific triggers, not the patient's subjective description of their symptoms 1, 2:
- Brief episodic (<1 minute): Triggered by head position changes → suspect BPPV 1, 2
- Acute persistent (days to weeks): Constant symptoms with nausea/vomiting → suspect vestibular neuritis, labyrinthitis, or posterior circulation stroke 1, 2
- Spontaneous episodic (minutes to hours): No positional trigger → suspect vestibular migraine or Ménière's disease 1, 2
- Chronic (weeks to months): Persistent symptoms → suspect medication side effects, anxiety/panic disorder, or posttraumatic vertigo 1, 2
Critical Associated Symptoms to Elicit
- Headache, photophobia, phonophobia: Strongly suggests vestibular migraine 1, 2
- Hearing loss, tinnitus, aural fullness: Suggests Ménière's disease 3, 2
- Focal neurological symptoms (dysarthria, diplopia, numbness, weakness): Red flags for central pathology requiring urgent imaging 1, 2
Migraine History is Essential
Given the patient's age, vestibular migraine is extremely common and often under-recognized 3, 4. Ask specifically about:
- Current or past migraine history 4
- Family history of migraine 4
- Motion intolerance as a trigger 3, 4
- Whether photophobia, phonophobia, or visual aura occur during vertigo episodes 4
Physical Examination: Targeted Maneuvers
Dix-Hallpike Maneuver (Gold Standard for BPPV)
Perform this maneuver in every patient with brief episodic dizziness triggered by position changes 1, 2. Skipping this test is a critical error that delays diagnosis and treatment 2.
Positive findings for BPPV 1, 2:
- Latency period of 5-20 seconds before symptoms begin
- Torsional, upbeating nystagmus toward the affected ear
- Vertigo and nystagmus that crescendo then resolve within 60 seconds
- Fatigability with repeated testing
Red flags suggesting central pathology 4, 2:
- Immediate onset without latency
- Purely vertical nystagmus without torsional component (downbeating is particularly concerning)
- Persistent nystagmus that doesn't fatigue
- Direction-changing nystagmus
Complete Neurologic Examination
Perform a thorough neurologic exam including 1, 2:
- Cranial nerve testing
- Cerebellar testing (finger-to-nose, heel-to-shin, rapid alternating movements)
- Gait assessment
- Observation for spontaneous nystagmus
Critical pitfall: 75-80% of patients with posterior circulation stroke have NO focal neurologic deficits, so a normal exam does not exclude stroke 1, 2.
HINTS Examination (For Acute Persistent Vertigo)
If the patient has acute vestibular syndrome (continuous dizziness lasting days), the HINTS examination (Head-Impulse, Nystagmus, Test of Skew) has 100% sensitivity for detecting stroke when performed by trained practitioners 1, 2. However, this examination is unreliable when performed by non-experts 1.
Red Flags Requiring Urgent Neuroimaging (MRI Brain Without Contrast)
Order MRI immediately if any of the following are present 1, 2:
- Focal neurological deficits
- Sudden unilateral hearing loss
- Inability to stand or walk (severe postural instability)
- Downbeating or other central nystagmus patterns
- New severe headache accompanying dizziness
- Progressive neurologic symptoms
- Failure to respond to appropriate peripheral vertigo treatments
Do not use CT head instead of MRI when stroke is suspected—CT has only 20-40% sensitivity for posterior circulation infarcts, which are the most common central cause of acute dizziness 1, 2.
When Imaging is NOT Indicated
Do not order imaging for 1, 2:
- Brief episodic vertigo with typical BPPV features on Dix-Hallpike
- Acute persistent vertigo with normal neurologic exam and peripheral findings
- Straightforward BPPV without additional concerning features
Routine imaging for isolated dizziness has a diagnostic yield of <1% and most findings are incidental 1.
Treatment Based on Diagnosis
BPPV (Most Likely in This Age Group)
Perform canalith repositioning procedure (Epley maneuver) immediately—this has 80% success after 1-3 treatments and 90-98% after repeat maneuvers 1, 2. No medications are needed for typical BPPV 1, 2. Counsel the patient about 10-18% recurrence rate at 1 year 2.
Vestibular Migraine (Second Most Likely)
Initiate migraine prophylaxis and lifestyle modifications 1, 2. Hearing loss in vestibular migraine is typically mild, absent, or stable over time—not fluctuating like Ménière's disease 4.
Vestibular Neuritis
Consider short course of vestibular suppressants (e.g., meclizine) for acute symptoms, but initiate vestibular rehabilitation therapy as soon as possible 5. Prolonged use of vestibular suppressants delays compensation 5.
Medication Review is Critical
In a 22-year-old, medication side effects are a leading reversible cause of chronic dizziness 1. Review antihypertensives, sedatives, anticonvulsants, and psychotropic drugs 1.
Common Pitfalls to Avoid
- Relying on patient's description of "spinning" versus "lightheadedness" instead of focusing on timing and triggers 1, 2
- Assuming normal neurologic exam excludes stroke (75-80% of posterior circulation strokes have no focal deficits) 1, 2
- Ordering imaging for straightforward BPPV, which delays treatment unnecessarily 2
- Skipping the Dix-Hallpike maneuver, the gold standard diagnostic test 2
- Overlooking vestibular migraine, which is extremely common but under-recognized in young patients 3, 4
- Failing to distinguish fluctuating hearing loss (Ménière's) from stable/absent hearing loss (vestibular migraine) 4