What is the approach to managing a 21-year-old female patient presenting with giddiness and vertigo?

Approach to a 21-Year-Old Female with Giddiness and Vertigo

Begin by categorizing the presentation based on timing and triggers rather than the patient's subjective description of "giddiness," as this classification determines the diagnostic pathway and urgency of evaluation. 1, 2

Initial Classification by Timing

Determine which of four vestibular syndromes applies 1, 2:

• Brief episodic (seconds to <1 minute): Triggered by specific head position changes → suggests BPPV 1
• Acute persistent (days to weeks): Continuous symptoms with nausea/vomiting → suggests vestibular neuritis, labyrinthitis, or posterior circulation stroke 1
• Spontaneous episodic (minutes to hours): No positional trigger → suggests vestibular migraine, Ménière's disease, or vertebrobasilar TIA 2
• Chronic (weeks to months): Persistent symptoms → suggests anxiety/panic disorder, medication side effects, or posterior fossa mass 1, 2

Critical History Elements

Ask specifically about 3, 1:

• Duration of each episode: Seconds (BPPV), hours (Ménière's/vestibular migraine), or days (vestibular neuritis)
• Positional triggers: Head movements triggering symptoms strongly suggest BPPV 1
• Hearing symptoms: Fluctuating hearing loss, tinnitus, or aural fullness indicate Ménière's disease 3, 1
• Headache features: Photophobia, phonophobia, or visual aura suggest vestibular migraine 3, 2
• Medications: Review antihypertensives, sedatives, anticonvulsants, and psychotropic drugs as leading reversible causes 1, 2

Common pitfall: Do not rely on whether the patient describes "spinning" versus "lightheadedness"—this distinction has poor diagnostic value. 3, 1

Physical Examination

Perform the Dix-Hallpike Maneuver

This is the gold standard for BPPV diagnosis 1, 4:

• Positive for BPPV: 5-20 second latency, torsional upbeating nystagmus toward the affected ear, symptoms crescendo then resolve within 60 seconds 1, 4
• Concerning for central cause: Immediate onset without latency, purely vertical nystagmus without torsional component, persistent nystagmus that doesn't fatigue 4

Assess Nystagmus Characteristics

Peripheral vertigo nystagmus 4:

• Horizontal with rotatory component
• Unidirectional
• Suppressed by visual fixation
• Fatigable with repeated testing

Central vertigo nystagmus 4:

• Pure vertical without torsional component
• Direction-changing without head position changes
• Not suppressed by visual fixation
• Baseline nystagmus without provocative maneuvers

Red Flags Requiring Urgent Neuroimaging

Any of these findings mandate immediate MRI brain without contrast 1, 4:

• Severe postural instability with falling 4
• New-onset severe headache with vertigo 1
• Any focal neurological deficits (dysarthria, diplopia, limb weakness, sensory deficits) 4
• Downbeating nystagmus on Dix-Hallpike without torsional component 4
• Failure to respond to appropriate peripheral vertigo treatments 4

Critical caveat: 75-80% of patients with posterior circulation stroke have NO focal neurologic deficits on standard examination, so absence of neurologic findings does not exclude stroke. 1, 2

HINTS Examination for Acute Vestibular Syndrome

If the patient has continuous vertigo lasting days with nausea/vomiting, perform HINTS (Head Impulse, Nystagmus, Test of Skew) 1:

• When performed by trained neurologists: 100% sensitivity for detecting stroke 1
• When performed by emergency physicians: Only 83% sensitivity and 44% specificity—unreliable for ruling out stroke 5

Therefore, if you are not specifically trained in HINTS examination, proceed directly to MRI brain without contrast for any acute vestibular syndrome in a patient with vascular risk factors. 1

Imaging Decisions

No imaging indicated for 1:

• Brief episodic vertigo with typical BPPV features on Dix-Hallpike
• Acute persistent vertigo with normal neurologic exam and peripheral features (if HINTS performed by trained examiner)

MRI brain without contrast indicated for 1:

• Abnormal neurologic examination
• Any red flags listed above
• Unilateral or pulsatile tinnitus (to exclude vestibular schwannoma)
• Asymmetric hearing loss

CT head has only 20-40% sensitivity for posterior circulation infarcts and should not be used instead of MRI when stroke is suspected. 1

Management Based on Diagnosis

BPPV (Most Common in Young Adults)

Perform canalith repositioning procedures (Epley maneuver) immediately—80% success after 1-3 treatments, 90-98% after repeat maneuvers. 1 No medications or imaging needed for typical cases. 1

Vestibular Neuritis

Vestibular suppressants (meclizine 25-100 mg daily in divided doses) for acute symptoms only 6, plus vestibular rehabilitation therapy 7

Ménière's Disease

Salt restriction and diuretics 7, with intratympanic dexamethasone or gentamicin for refractory cases 8

Vestibular Migraine

Migraine prophylaxis and lifestyle modifications 3, 2

Medication-Induced

Review and discontinue offending agents—this is one of the most common and reversible causes in young patients 1, 2

Special Considerations for Young Female Patients

In a 21-year-old female, prioritize 2, 7:

1. BPPV (most common cause—42% of peripheral vertigo cases) 2
2. Vestibular migraine (especially if migraine history, often under-recognized) 2
3. Anxiety/panic disorder (common in young adults with chronic dizziness) 1
4. Medication side effects (review any recent medication changes) 1

Stroke is uncommon in this age group without vascular risk factors, but never assume it's impossible—maintain vigilance for red flags. 1, 4