What is the appropriate workup for a male patient with hypertension and gout presenting with vertigo?

Workup for Vertigo in a Male with Hypertension and Gout

Begin by categorizing the vertigo based on timing and triggers—brief episodic (seconds to minutes), acute persistent (days to weeks), or chronic (weeks to months)—as this classification drives the entire diagnostic approach and determines whether imaging is needed. 1

Initial Clinical Assessment

Critical History Elements

• Duration and onset: Determine if symptoms last seconds (suggesting BPPV), hours (suggesting Ménière's disease or vestibular migraine), days to weeks (suggesting vestibular neuritis), or are chronic 1, 2
• Triggers: Ask specifically about head position changes, standing up, or neck movements 1, 2
• Associated symptoms:
  • Hearing loss, tinnitus, or aural fullness strongly suggest peripheral causes like Ménière's disease 3, 4
  • Headache, diplopia, dysarthria, numbness, or weakness indicate central causes requiring urgent evaluation 1, 2
• Medication review: Antihypertensive medications are a leading reversible cause of chronic dizziness, particularly when causing orthostatic hypotension 1, 5

Physical Examination

• Perform Dix-Hallpike maneuver for suspected BPPV: Look for 5-20 second latency, torsional upbeating nystagmus toward the affected ear, and symptoms resolving within 60 seconds 1, 2
• Observe for spontaneous nystagmus: Horizontal or horizontal-rotatory nystagmus suggests peripheral causes; pure vertical nystagmus strongly suggests central pathology 3, 2
• Complete neurologic examination: Identify focal deficits (cranial nerve abnormalities, cerebellar signs, weakness) that indicate central causes 2, 6
• Orthostatic vital signs: Measure blood pressure lying and standing, as orthostatic hypotension from antihypertensive medications is common in this population 5, 7

Diagnostic Algorithm Based on Clinical Presentation

Brief Episodic Vertigo (Seconds to Minutes)

• If Dix-Hallpike is positive with typical findings: Diagnose BPPV—no imaging or laboratory testing needed 8, 1
• If Dix-Hallpike is negative or atypical features present: Consider MRI head without contrast to exclude central pathology 8, 2

Acute Persistent Vertigo (Days to Weeks)

• If neurologic examination is normal AND trained examiner performs HINTS examination showing peripheral features: No imaging needed; diagnose vestibular neuritis or labyrinthitis 8, 1
• If neurologic examination is abnormal OR HINTS suggests central cause (absent head impulse test, direction-changing nystagmus, vertical skew deviation): Obtain MRI head without contrast urgently 8, 2
• If patient has high vascular risk (hypertension, age >50, diabetes, prior stroke): Obtain MRI head without contrast even with normal neurologic examination, as 11-25% may have posterior circulation stroke 8, 3

Chronic Vertigo (Weeks to Months)

• Review all medications first: Adjust or discontinue antihypertensive agents if orthostatic hypotension is documented 1, 5
• Screen for anxiety and depression: These are common causes of chronic dizziness 1
• If progressive symptoms or red flags present: Obtain MRI head without contrast to exclude posterior fossa mass 1, 2

Specific Considerations for Hypertension and Gout

Hypertension-Related Issues

• Vertigo in hypertensive patients is rarely caused by elevated blood pressure itself but rather by associated conditions or medication side effects 5
• Orthostatic hypotension from antihypertensive medications is a common reversible cause—perform orthostatic vital sign measurements 5, 7
• Hypertension is a vascular risk factor that lowers the threshold for obtaining MRI in acute vestibular syndrome, even without focal neurologic deficits 2

Gout-Related Considerations

• Patients with gout have a 1.17-fold increased risk of peripheral vertigo, particularly BPPV, compared to the general population 9
• Gout medications (colchicine, NSAIDs) can cause dizziness as a side effect—review current medications 8
• If treating acute gout flare with colchicine: Use caution as it can cause neurotoxicity, especially with renal impairment or concurrent statin use 8

Red Flags Requiring Urgent Evaluation

Any of the following mandate immediate MRI head without contrast and neurologic consultation: 1, 2

• Focal neurologic deficits (diplopia, dysarthria, dysphagia, weakness, numbness)
• Sudden hearing loss
• New severe headache
• Inability to stand or walk
• Pure vertical or direction-changing nystagmus
• Downbeating nystagmus

Imaging Guidelines

When Imaging is NOT Indicated

• Typical BPPV with positive Dix-Hallpike test and no red flags 8, 1
• Acute persistent vertigo with normal neurologic examination, HINTS consistent with peripheral cause by trained examiner, and no vascular risk factors 8, 1

When MRI Head Without Contrast IS Indicated

• Abnormal neurologic examination 8, 2
• HINTS examination suggesting central cause 8, 2
• High vascular risk patients (hypertension, age >50) with acute vestibular syndrome 8, 2
• Unilateral or pulsatile tinnitus 2
• Asymmetric hearing loss 2
• Progressive symptoms suggesting mass lesion 1

Avoid CT Head

• CT has very low diagnostic yield (<1%) for isolated dizziness and misses most posterior circulation infarcts 8, 1
• MRI with diffusion-weighted imaging is far superior (4% diagnostic yield vs <1% for CT) 1, 2

Treatment Considerations

For BPPV

• Perform canalith repositioning procedures (Epley maneuver) as first-line treatment with 90-98% success rate 1, 2
• Medications are unnecessary for typical BPPV 1
• Meclizine 25-100 mg daily may be used for symptomatic relief of vestibular vertigo but does not treat the underlying cause 10

For Medication-Induced Dizziness

• Adjust antihypertensive regimen if orthostatic hypotension is documented 5
• Consider losartan or calcium channel blockers for hypertension management in gout patients, as recommended by EULAR guidelines 8

Critical Pitfalls to Avoid

• Do not assume normal neurologic examination excludes stroke: 75-80% of patients with posterior circulation infarction lack focal neurologic deficits 3, 2
• Do not rely on patient's description of "spinning" vs "lightheadedness": Focus on timing and triggers instead 1, 2
• Do not order CT when stroke is suspected: CT misses most posterior circulation infarcts—use MRI 8, 1
• Do not overlook medication review: This is one of the most common and reversible causes of chronic dizziness in hypertensive patients 1, 5
• Do not order routine imaging for typical BPPV: This delays treatment and has no diagnostic value 8, 1