What is the appropriate workup for a patient with intermittent vertigo, no hearing changes, and a normal neuro exam?

Workup for Intermittent Vertigo Without Hearing Changes and Normal Neuro Exam

For a patient with intermittent vertigo, no hearing changes, and a normal neurologic examination, perform the Dix-Hallpike maneuver as the primary diagnostic test—if positive for BPPV, no imaging or additional testing is needed. 1

Initial Diagnostic Approach

Focus on timing and triggers rather than the patient's subjective description of dizziness. 1 Intermittent vertigo falls into the "triggered episodic vestibular syndrome" category, where episodes last seconds to minutes and are provoked by specific movements. 1

Essential History Elements

• Duration of episodes: Brief episodic vertigo (seconds to minutes) triggered by head movements strongly suggests BPPV. 1
• Specific triggers: Positional changes (rolling over in bed, looking up, bending forward) point to BPPV. 1
• Associated symptoms: The absence of hearing loss, tinnitus, or aural fullness makes Ménière's disease unlikely and supports a peripheral cause. 2
• Headache features: Assess for photophobia and phonophobia, which would suggest vestibular migraine. 1
• Vascular risk factors: Document age >50, hypertension, diabetes, or prior stroke, as these increase posterior circulation stroke risk even with normal exam. 1

Physical Examination

Perform the Dix-Hallpike maneuver immediately—this is the gold standard diagnostic test for BPPV. 1 Positive findings include:

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

Examine nystagmus characteristics carefully: 2

• Horizontal or horizontal-rotatory nystagmus suggests peripheral cause 2
• Pure vertical nystagmus strongly suggests central pathology requiring imaging 2
• Direction-changing nystagmus warrants imaging 1

When Imaging Is NOT Indicated

No imaging is needed if: 1

• Dix-Hallpike test is positive for BPPV 1
• Neurologic examination remains normal 1
• No red flag symptoms are present 1

Critical pitfall to avoid: Do not order routine CT or MRI for straightforward BPPV with positive Dix-Hallpike and no concerning features—this delays treatment and has extremely low diagnostic yield (<1% for CT). 1

When Imaging IS Indicated

Order MRI brain without contrast (NOT CT) if any of the following are present: 1

• High vascular risk patients (age >50, hypertension, diabetes, prior stroke)—even with normal exam, 11-25% may have posterior circulation stroke 1
• Focal neurologic deficits on examination 1
• Atypical nystagmus patterns (vertical, direction-changing, or persistent without fixation) 1, 2
• Unilateral or pulsatile tinnitus 1
• Asymmetric hearing loss (contradicts your scenario but important to assess) 1
• Progressive neurologic symptoms 1
• New severe headache accompanying vertigo 1
• Inability to stand or walk 1
• Downbeating nystagmus 1

Why MRI over CT: MRI with diffusion-weighted imaging has 4% diagnostic yield versus <1% for CT, and CT misses most posterior circulation infarcts. 1

Additional Testing NOT Routinely Needed

• Comprehensive vestibular testing: Not indicated for straightforward BPPV—it is unnecessary and delays treatment. 1
• Audiometry: Not needed in the absence of hearing complaints, tinnitus, or aural fullness. 1
• CT angiography: Has only 14% sensitivity and 3% diagnostic yield for isolated dizziness. 1
• Laboratory tests: Not indicated for typical BPPV presentation. 1

Critical Warning About "Normal" Neuro Exam

Do not assume a normal neurologic examination excludes stroke—75-80% of patients with acute vestibular syndrome from posterior circulation infarction have no focal neurologic deficits. 2 This is why vascular risk factors matter even with normal exam findings.

If Dix-Hallpike Is Negative or Equivocal

Consider alternative diagnoses and reassess for: 1

• Vestibular migraine (headache, photophobia, phonophobia) 1
• Medication side effects (review antihypertensives, sedatives, anticonvulsants, psychotropics) 1
• Anxiety or panic disorder 1
• Posttraumatic vertigo (history of head trauma) 1

In these cases, vestibular testing may be appropriate only if the clinical presentation is atypical or additional symptoms suggest concurrent CNS or otologic disorders. 1