Triage for Dizziness

Immediate Triage: Rule Out Life-Threatening Causes First

All patients with dizziness require immediate ECG to evaluate for ventricular or supraventricular arrhythmias, pre-excitation, and prolonged QT interval, as cardiac arrhythmias can cause syncope and sudden death. 1

Red Flags Requiring Immediate Hospitalization

Syncope or suspected ventricular arrhythmia - requires immediate hospitalization for monitoring and management 1
Palpitations with syncope - never ignore this combination, requires immediate hospitalization 1
Focal neurological deficits - suggests posterior circulation stroke 1, 2
Sudden hearing loss - requires urgent evaluation 1, 2
Inability to stand or walk - indicates severe vestibular or central pathology 1, 2
New severe headache - mandates immediate imaging and neurologic consultation 3
Downbeating nystagmus or other central nystagmus patterns - suggests central pathology 1, 3

Critical Pitfall to Avoid

Do not assume a normal neurological examination excludes stroke - 75-80% of patients with posterior circulation stroke do not have focal neurologic deficits. 1, 3

Categorize by Timing and Triggers (Not Symptom Quality)

Focus on timing and triggers rather than the patient's subjective description of "spinning" versus "lightheadedness," as symptom quality does not reliably distinguish benign from dangerous causes. 1, 2, 3

Four Key Vestibular Syndromes

Acute Vestibular Syndrome (AVS) - acute persistent dizziness lasting days to weeks with constant symptoms 2, 3
Triggered Episodic Vestibular Syndrome - brief episodes (seconds to minutes) triggered by head movements, suggesting BPPV 2, 3
Spontaneous Episodic Vestibular Syndrome - episodes lasting minutes to hours without positional triggers, suggesting vestibular migraine or TIA 2, 4, 5
Chronic Vestibular Syndrome - persistent symptoms lasting weeks to months 2, 3

Triage Algorithm by Syndrome

For Acute Vestibular Syndrome (Days to Weeks of Constant Dizziness)

Perform HINTS examination (Head Impulse, Nystagmus, Test of Skew) - this has 100% sensitivity for detecting stroke when performed by trained practitioners, superior to early MRI which has only 46% sensitivity. 2, 3

HINTS Examination Components:

Head Impulse Test - abnormal (corrective saccade) suggests peripheral cause; normal suggests central cause 2, 3
Nystagmus - unidirectional horizontal nystagmus suggests peripheral; direction-changing or vertical nystagmus suggests central 2, 3
Test of Skew - vertical misalignment suggests central cause 2, 3

Imaging Decisions:

No imaging needed if HINTS consistent with peripheral vertigo by trained examiner AND normal neurologic exam 2, 3
MRI brain without contrast immediately if HINTS suggests central cause, abnormal neurologic exam, or high vascular risk patients (hypertension, atrial fibrillation, age >50) 1, 2, 3
Do not use CT instead of MRI - CT misses many posterior circulation infarcts with only 20-40% sensitivity 1, 3

Warning: When HINTS is performed by non-experts, results are less reliable - if uncertain, obtain MRI for high-risk patients. 2, 3

For Triggered Episodic Vestibular Syndrome (Seconds of Dizziness with Head Movement)

Perform Dix-Hallpike maneuver immediately - this is the gold standard for diagnosing BPPV. 1, 2, 3

Diagnostic Criteria for BPPV:

Latency period of 5-20 seconds before symptoms begin 2, 3
Torsional, upbeating nystagmus toward the affected ear 2, 3
Vertigo and nystagmus increase then resolve within 60 seconds 2, 3

Management:

Positive Dix-Hallpike with typical features: No imaging needed - proceed directly to Epley maneuver with 90-98% success rate 1, 2, 3
Atypical features or equivocal findings - obtain MRI brain to exclude posterior fossa lesions 2, 3

For Spontaneous Episodic Vestibular Syndrome (Minutes to Hours Without Triggers)

Assess for associated symptoms to differentiate vestibular migraine from TIA. 2, 4, 5

Vestibular Migraine Features:

Headache, photophobia, phonophobia 3
History of migraines 2
Episodes lasting minutes to hours 2, 3

TIA Features (High-Risk):

Vascular risk factors (hypertension, atrial fibrillation, diabetes) 2, 3
Non-whirling type of dizziness 2
Age >50 years 2

High vascular risk patients require MRI brain without contrast even with normal neurologic examination. 2, 3

For Chronic Vestibular Syndrome (Weeks to Months)

Perform comprehensive medication review first - this is a leading reversible cause of chronic dizziness. 3

Key Medications to Review:

Antihypertensives 3
Sedatives 3
Anticonvulsants 3
Psychotropic drugs 3

Associated Symptoms Guide Diagnosis:

Hearing loss, tinnitus, aural fullness - suggests Ménière's disease, obtain MRI head and IAC with contrast to exclude vestibular schwannoma 2, 3
Anxiety, panic symptoms - psychiatric causes are common in chronic dizziness 3
History of head trauma - posttraumatic vertigo can persist chronically 3
Progressive neurologic symptoms - obtain MRI brain to evaluate for posterior fossa mass 3

Imaging not routinely indicated unless red flags present - when needed, use MRI brain without contrast, not CT. 2, 3

Essential Laboratory Tests

Obtain glucose, electrolytes, and renal function, especially in patients on diuretics or with history of renal disease. 1

Common Pitfalls to Avoid in Triage

Do not rely on patient's description of symptom quality - focus on timing and triggers instead 1, 3
Do not assume normal neurologic exam excludes stroke - most posterior circulation strokes lack focal deficits 1, 3
Do not order CT when stroke is suspected - use MRI with diffusion-weighted imaging 1, 3
Do not order imaging for typical BPPV with positive Dix-Hallpike - this delays treatment and is unnecessary 2, 3
Do not ignore palpitations with dizziness - obtain ECG immediately to evaluate for life-threatening arrhythmias 1
Do not overlook medication side effects - review all medications as a reversible cause 3

Disposition Decisions

Immediate Hospitalization Required:

Syncope or suspected ventricular arrhythmia 1
PR interval >240 ms, QRS duration >120 ms, or second/third-degree AV block 1
Non-sinus rhythm or conduction abnormalities on ECG 1
Focal neurological deficits 1, 2
HINTS examination suggesting central cause 2, 3
New severe headache 3

Outpatient Management Appropriate:

Typical BPPV with positive Dix-Hallpike and no red flags - treat with Epley maneuver 1, 2, 3
Peripheral vestibular syndrome with normal HINTS by trained examiner and no vascular risk factors 2, 3
Vestibular migraine without vascular risk factors - initiate migraine prophylaxis 1, 2

Follow-Up Within One Month:

All patients treated for BPPV to document resolution or persistence 3
Patients with persistent symptoms despite initial treatment - consider vestibular rehabilitation therapy 3

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