What is the appropriate evaluation and management for a patient presenting with dizziness and lightheadedness?

Evaluation and Management of Dizziness and Lightheadedness

Categorize the patient by timing and triggers rather than symptom quality—this framework directly guides your physical examination and distinguishes benign peripheral vestibular disorders from dangerous central causes like stroke. 1

Initial Classification by Vestibular Syndrome

Focus on three key questions to classify the presentation 1, 2:

Acute Vestibular Syndrome (AVS)

• Constant vertigo lasting days to weeks with nausea, vomiting, and gait instability 1
• Perform HINTS examination (Head Impulse, Nystagmus, Test of Skew) immediately—this has 100% sensitivity for posterior circulation stroke when performed by trained practitioners, superior to early MRI (46% sensitivity) 1, 2
• Critical pitfall: 75-80% of patients with posterior circulation stroke have NO focal neurologic deficits 2, 3
• Differential: vestibular neuritis (peripheral) vs. posterior circulation stroke (central) 1, 4

Triggered Episodic Vestibular Syndrome

• Brief episodes (seconds to <1 minute) triggered by head position changes 1, 2
• Perform Dix-Hallpike maneuver immediately—this is the gold standard for diagnosing BPPV 2, 3
• Positive test shows: 5-20 second latency, torsional upbeating nystagmus toward affected ear, symptoms resolve within 60 seconds 2, 3
• No imaging needed for typical BPPV with positive Dix-Hallpike 1, 2

Spontaneous Episodic Vestibular Syndrome

• Episodes lasting minutes to hours without positional triggers 1, 2
• Associated symptoms guide diagnosis:
  • Headache, photophobia, phonophobia → vestibular migraine 1, 2, 3
  • Hearing loss, tinnitus, aural fullness → Ménière's disease 1, 2, 3

Critical History Elements

Duration is more diagnostically valuable than the patient's description of "spinning" vs "lightheadedness" 2, 3:

• Seconds: BPPV 1, 2
• Minutes to hours: vestibular migraine, Ménière's disease 1, 2
• Days to weeks: vestibular neuritis, stroke 1, 2
• Weeks to months: medication side effects, anxiety/panic disorder, posttraumatic vertigo 2, 3

Essential Physical Examination

Perform a complete neurologic examination including 1, 2:

• Orthostatic vital signs: drop of ≥20 mmHg systolic or ≥10 mmHg diastolic suggests orthostatic hypotension 5, 6
• Dix-Hallpike maneuver for all patients with triggered symptoms 1, 2, 3
• HINTS examination for acute vestibular syndrome (only if trained) 1, 2
• Cranial nerve testing, cerebellar testing, gait assessment 1, 3
• Assessment for spontaneous nystagmus 1, 3

Imaging Decisions

No Imaging Indicated 1, 2:

• Brief episodic vertigo with typical BPPV features and positive Dix-Hallpike
• Acute persistent vertigo with normal neurologic exam and HINTS consistent with peripheral vertigo (by trained examiner)
• Lightheadedness from orthostatic hypotension, dehydration, or anxiety 5

MRI Brain Without Contrast Indicated 1, 2:

• Abnormal neurologic examination
• HINTS examination suggesting central cause
• High vascular risk patients with acute vestibular syndrome
• Unilateral or pulsatile tinnitus
• Asymmetric hearing loss
• New severe headache accompanying dizziness
• Inability to stand or walk
• Downbeating or other central nystagmus patterns

Critical Pitfall:

CT head has very low yield (<1% diagnostic yield) and only 20-40% sensitivity for posterior circulation infarcts—never use CT instead of MRI when stroke is suspected 5, 1, 2

Treatment Based on Diagnosis

BPPV 1, 2, 3:

• Canalith repositioning procedures (Epley maneuver) as first-line treatment
• 80% success after 1-3 treatments, 90-98% after repeat maneuvers
• No medications needed for typical BPPV
• Reassess within one month

Vestibular Migraine 1, 2, 3:

• Migraine prophylaxis and lifestyle modifications
• Consider vestibular rehabilitation if symptoms persist

Ménière's Disease 1, 2, 6:

• Salt restriction and diuretics first-line
• Intratympanic dexamethasone or gentamicin for refractory cases

Vestibular Neuritis 1, 3, 4:

• Vestibular rehabilitation therapy as soon as possible
• Short-term vestibular suppressants (3-5 days maximum) to avoid delaying central compensation

Orthostatic Hypotension 5, 6:

• Review and adjust medications (antihypertensives, sedatives, anticonvulsants)
• Alpha agonists or mineralocorticoids if medication adjustment insufficient
• Lifestyle modifications: increased fluid/salt intake, compression stockings

Posterior Circulation Stroke 1, 2:

• Activate stroke protocol immediately
• Urgent neurology consultation
• MRI brain with diffusion-weighted imaging

Red Flags Requiring Urgent Evaluation 1, 2, 3

• Focal neurological deficits (dysarthria, diplopia, numbness, weakness)
• Sudden unilateral hearing loss
• Inability to stand or walk
• Downbeating nystagmus or other central nystagmus patterns
• New severe headache
• Progressive neurologic symptoms
• Failure to respond to appropriate vestibular treatments

Common Pitfalls to Avoid

• Don't rely on patient's description of "spinning" vs "lightheadedness"—focus on timing and triggers instead 2, 3
• Don't assume normal neurologic exam excludes stroke—most posterior circulation strokes have no focal deficits 2, 3
• Don't order imaging for straightforward BPPV—this delays treatment unnecessarily 2, 3
• Don't skip the Dix-Hallpike maneuver—it's the gold standard diagnostic test 2, 3
• Don't overlook vestibular migraine—it's extremely common but under-recognized, especially in young patients 3
• Don't use CT when stroke is suspected—it misses most posterior circulation infarcts 5, 1, 2

Special Considerations for Lightheadedness/Presyncope

Lightheadedness related to systemic causes (dehydration, hypotension, vasovagal reaction, anxiety) is often diagnosed clinically and does not require CNS imaging 5. Consider:

• Medication review (leading reversible cause of chronic dizziness) 2, 3
• Cardiac evaluation if symptoms suggest bradycardia or arrhythmia—ambulatory ECG monitoring is reasonable for symptoms of unclear etiology 5
• Psychiatric screening for anxiety, panic disorder, depression 2, 6
• Autonomic dysfunction if persistent isolated dizziness without clear orthostatic pattern 5