What is the appropriate evaluation and management approach for a patient presenting with dizziness, considering their past medical history and potential underlying conditions such as hypertension, diabetes, or cardiovascular disease?

Evaluation of a Patient with Dizziness

Initial History: Focus on Timing and Triggers

The most critical step is categorizing dizziness by timing and triggers rather than the patient's vague descriptors like "spinning" or "lightheadedness," as these subjective descriptions are unreliable and of limited clinical value. 1, 2, 3

Key Timing Categories to Identify:

• Brief episodic (seconds to <1 minute) triggered by head position changes → suggests BPPV 1, 2, 3
• Acute persistent (days to weeks) with constant symptoms → suggests acute vestibular syndrome requiring differentiation between peripheral versus central causes 1, 2
• Recurrent episodic (minutes to hours) → consider vestibular migraine or Ménière disease 1, 2
• Chronic (weeks to months) → consider medication effects, psychiatric causes, or posttraumatic vertigo 1, 3

Essential Associated Symptoms to Elicit:

• Hearing loss, tinnitus, or aural fullness → suggests Ménière disease 4, 1, 2
• Headache, photophobia, or phonophobia → suggests vestibular migraine 4, 1, 3
• Neurological symptoms (diplopia, dysarthria, numbness, weakness, new severe headache) → suggests central pathology requiring urgent evaluation 1, 2, 3

Critical Medical History Elements:

• Cardiovascular risk factors: hypertension, diabetes, atrial fibrillation increase stroke risk 4, 2, 3
• Medication review: antihypertensives, sedatives, anticonvulsants, psychotropic drugs are leading causes of chronic dizziness 3
• History of head trauma: posttraumatic BPPV requires more treatments (67% vs 14% for non-traumatic) and may be bilateral 4
• Migraine history: essential for differentiating vestibular migraine from Ménière disease 4
• Fall history: particularly in elderly patients, ask CDC screening questions about falls in past year, feeling unsteady, and worry about falling 4

Physical Examination: Systematic Approach

Observation for Spontaneous Nystagmus:

• Observe at rest for spontaneous nystagmus patterns 1, 2
• Central patterns (downbeating, direction-changing without position change) are red flags requiring urgent imaging 1, 3

Positional Testing for BPPV:

Perform the Dix-Hallpike maneuver for all patients with triggered episodic symptoms 4, 1, 2

Diagnostic criteria for positive Dix-Hallpike:

• Latency period of 5-20 seconds before symptoms begin 1, 3
• Torsional upbeating nystagmus toward the affected ear 4, 1
• Vertigo and nystagmus that increase then resolve within 60 seconds 1, 3

Perform supine roll test to assess for horizontal canal BPPV, looking for direction-changing geotropic or apogeotropic nystagmus that is distinctly stronger on one side 4

HINTS Examination (for Acute Vestibular Syndrome):

For patients with acute persistent vertigo lasting days, perform the HINTS examination (Head-Impulse, Nystagmus, Test of Skew) which has 100% sensitivity for detecting stroke when performed by trained practitioners, superior to early MRI (46% sensitivity) 1, 3, 5

Critical caveat: HINTS is less reliable when performed by non-experts, so if uncertain, proceed with imaging 3

Complete Neurologic Examination:

• Cranial nerve testing 1
• Cerebellar testing (finger-to-nose, heel-to-shin, rapid alternating movements) 1
• Gait assessment including tandem gait 1
• Orthostatic blood pressure measurement 5, 6

Important pitfall: 75-80% of patients with posterior circulation stroke have NO focal neurologic deficits, so normal exam does not exclude stroke 1, 3

Laboratory Testing

Routine laboratory testing has extremely low yield in patients with isolated dizziness and normal examination 1

Consider only:

• Bedside glucose testing if appropriate clinical context 1
• Pregnancy testing in women of childbearing age if indicated 1

Imaging Indications

Imaging is NOT routinely indicated for most dizziness cases 2, 3

DO NOT Order Imaging For:

• Typical BPPV with positive Dix-Hallpike and no concerning features 1, 2, 3
• Peripheral vertigo with normal neurologic exam and reassuring HINTS by trained examiner 3

Order MRI Brain (Without Contrast) For:

• Red flag features: focal neurological deficits, sudden unilateral hearing loss, inability to stand or walk, downbeating or other central nystagmus patterns, new severe headache, progressive neurologic symptoms 1, 2, 3
• High vascular risk patients with acute vestibular syndrome even with normal neurologic examination 2, 3
• HINTS examination suggesting central cause 2, 3
• Unilateral or pulsatile tinnitus to exclude vestibular schwannoma 2, 3

Critical pitfall: CT head has very low sensitivity (20-40%) for posterior circulation stroke and should NOT be used instead of MRI when central pathology is suspected 2, 3

Assessment for Fall Risk (Especially Elderly)

In elderly patients with BPPV, conduct falls risk screening using CDC questions 4:

1. Have you had a fall in the past year? How many times? Were you injured?
2. Do you feel unsteady when standing or walking?
3. Do you worry about falling?

If positive responses, perform detailed falls risk assessment using Get Up and Go test, Tinetti Balance Assessment, or Berg Balance Scale 4

Common Pitfalls to Avoid

• Skipping the Dix-Hallpike maneuver when it is the gold standard diagnostic test for BPPV 1
• Ordering imaging for straightforward BPPV without concerning features, which delays treatment unnecessarily 1
• Assuming normal neurologic exam excludes stroke, as most posterior circulation strokes lack focal deficits 1, 3
• Relying on symptom quality alone rather than timing and triggers 1, 2, 3
• Using CT instead of MRI when stroke is suspected 2, 3