What is the appropriate workup for a patient presenting with dizziness?

Workup of Dizziness

The workup of dizziness should be guided by categorizing patients based on timing and triggers rather than subjective symptom descriptions, with focused bedside examination determining the need for imaging—which is rarely indicated for typical peripheral causes. 1, 2

Initial Clinical Categorization

The first step is to classify dizziness into one of four vestibular syndromes based on timing and triggers 1, 2:

• Triggered Episodic Vestibular Syndrome (t-EVS): Brief episodes (seconds to minutes) provoked by specific head movements—most commonly BPPV 3, 1
• Acute Vestibular Syndrome (AVS): Acute persistent vertigo lasting days to weeks with constant symptoms 3, 4
• Spontaneous Episodic Vestibular Syndrome (s-EVS): Recurrent episodes without positional triggers 1
• Chronic Vestibular Syndrome: Persistent symptoms lasting weeks to months 2, 4

Avoid the common pitfall of relying on patient descriptions of "spinning" versus "lightheadedness"—these subjective characterizations have poor diagnostic value. 1, 4

Essential History Elements

Focus your history on these specific diagnostic features 2, 4:

• Duration: Seconds (<1 minute suggests BPPV), minutes to hours (suggests Menière's or vestibular migraine), or days to weeks (suggests vestibular neuritis or stroke) 1, 4
• Triggers: Positional changes (BPPV), no trigger (vestibular neuritis), or associated with headache/photophobia (vestibular migraine) 2, 4
• Associated symptoms: Hearing loss, tinnitus, or aural fullness strongly suggest Menière's disease, labyrinthitis, or vestibular schwannoma 1, 2
• Neurologic symptoms: Headache, diplopia, dysarthria, numbness, or weakness indicate potential central causes requiring urgent evaluation 2, 4
• Vascular risk factors: Hypertension, atrial fibrillation, age >50, diabetes, or prior stroke increase stroke risk to 11-25% even with normal neurologic exam 4

Critical Physical Examination Maneuvers

For Triggered Episodic Symptoms (Suspected BPPV)

Perform the Dix-Hallpike maneuver as the gold standard diagnostic test 1, 2:

• Positive findings include: 5-20 second latency before symptoms begin, torsional upbeating nystagmus toward the affected ear, and symptoms that increase then resolve within 60 seconds 1, 4
• If positive with typical features, no imaging or laboratory testing is needed 2, 4

For Acute Vestibular Syndrome

The HINTS examination (Head Impulse, Nystagmus, Test of Skew) has 100% sensitivity for detecting stroke when performed by trained practitioners—superior to early MRI which has only 46% sensitivity 1, 4:

• However, HINTS is less reliable when performed by non-experts, so if you lack specialized training, proceed with imaging for high-risk patients 3, 4
• Observe for spontaneous nystagmus in all patients 2
• Complete neurologic examination to identify focal deficits suggesting central pathology 2

Additional Bedside Tests

• Orthostatic blood pressure measurement to assess for presyncope 2
• Supine roll test for horizontal canal BPPV 2

Imaging Indications—When to Order and What to Order

When Imaging is NOT Indicated

Do not order imaging for 3, 2, 4:

• Brief episodic vertigo with positive Dix-Hallpike test and typical BPPV features
• Acute persistent vertigo with normal neurologic exam AND HINTS examination showing peripheral features (when performed by trained examiner)
• Straightforward BPPV with no additional concerning features

The diagnostic yield of CT head in isolated dizziness is less than 1%, and it misses most posterior circulation infarcts 3, 4

When Imaging IS Indicated

Order MRI brain without contrast (NOT CT) for 3, 2, 4:

• Acute persistent vertigo with abnormal neurologic examination
• HINTS examination suggesting central cause
• High vascular risk patients (hypertension, age >50, diabetes, prior stroke) with acute vestibular syndrome—even with normal neurologic exam
• Unilateral or pulsatile tinnitus (to exclude vestibular schwannoma or vascular malformation)
• Asymmetric hearing loss
• Focal neurologic deficits
• Atypical nystagmus patterns (downbeating or central patterns)
• Progressive neurologic symptoms
• New severe headache accompanying dizziness

MRI with diffusion-weighted imaging has 4% diagnostic yield in isolated dizziness (versus <1% for CT), with ischemic stroke being the most common finding in 70% of positive cases 2, 4

Special Imaging Considerations

• MRI head and internal auditory canal (IAC) with contrast: For suspected Menière's disease with hearing loss/tinnitus to exclude vestibular schwannoma 2
• CT temporal bone: May be used for suspected structural abnormalities of the ear 2
• CTA head and neck: Only appropriate for pulsatile tinnitus to evaluate vascular malformations—NOT for routine isolated dizziness (diagnostic yield only 3%) 4

Red Flags Requiring Urgent Evaluation

These findings mandate immediate imaging and neurologic consultation 2, 4:

• Focal neurological deficits
• Sudden hearing loss
• Inability to stand or walk
• Downbeating nystagmus or other central nystagmus patterns
• New severe headache
• Failure to respond to appropriate vestibular treatments

Critical pitfall: 75-80% of patients with posterior circulation stroke have NO focal neurologic deficits on standard examination—do not assume normal exam excludes stroke 1, 4

Laboratory Testing

Laboratory testing is rarely helpful in the workup of dizziness 2:

• Consider only when specific systemic conditions are suspected based on history (e.g., anemia, thyroid dysfunction, electrolyte abnormalities)
• Not routinely indicated for typical vestibular syndromes

Medication Review

Medication side effects are a leading reversible cause of chronic dizziness 4:

• Review antihypertensives, sedatives, anticonvulsants, and psychotropic drugs
• Consider medication adjustment before extensive workup in chronic cases

Treatment Considerations Based on Diagnosis

BPPV (Most Common Cause)

Perform canalith repositioning procedures (Epley maneuver) immediately—80% success after 1-3 treatments, 90-98% with repeat maneuvers 2, 4:

• No medications are necessary for typical BPPV 4
• Reassess within one month to document resolution 4
• Counsel about 10-18% recurrence risk at one year 2

Vestibular Neuritis

• Vestibular suppressants (meclizine 25-100 mg daily in divided doses) for acute symptom relief 5
• Vestibular rehabilitation therapy for persistent symptoms 2, 4

Persistent Dizziness After Initial Treatment

Vestibular rehabilitation therapy is the primary intervention, significantly improving gait stability compared to medication alone 4:

• Particularly beneficial for elderly patients or those with heightened fall risk
• Includes habituation exercises, gaze stabilization, balance retraining, and fall prevention 4

Special Considerations for Elderly Patients

Dizziness increases fall risk 12-fold in elderly patients 4:

• Document number of falls in past year, circumstances, and injuries
• BPPV is present in 9% of elderly patients referred for geriatric evaluation—three-fourths had fallen within prior 3 months 4
• Consider home safety assessment and supervision for frail elderly patients 4