What is the best course of action for a patient experiencing dizziness without disequilibrium?

Dizziness Without Disequilibrium: Clinical Approach

For patients presenting with dizziness without disequilibrium, imaging is usually not indicated, and management should focus on identifying the specific vestibular syndrome through timing and triggers rather than the patient's subjective description of symptoms. 1

Initial Clinical Assessment

The key to evaluating dizziness without disequilibrium is categorizing the presentation by timing and triggers, not by vague patient descriptions like "spinning" versus "lightheadedness." 2, 3

Critical History Elements to Obtain

• Duration of episodes: Seconds to minutes suggests benign paroxysmal positional vertigo (BPPV); hours suggests Ménière's disease or vestibular migraine; days to weeks suggests acute vestibular syndrome. 2
• Triggers: Head position changes strongly suggest BPPV, while spontaneous episodes without triggers suggest other etiologies. 2
• Associated symptoms: Hearing loss or tinnitus suggests Ménière's disease; headache with photophobia/phonophobia suggests vestibular migraine; neurological symptoms (diplopia, dysarthria, weakness) raise concern for central causes. 1, 2
• Medication review: Antihypertensives, sedatives, anticonvulsants, and psychotropic drugs are leading reversible causes of chronic dizziness. 3

Essential Physical Examination Maneuvers

• Observe for spontaneous nystagmus in all patients with dizziness. 2
• Perform the Dix-Hallpike maneuver for suspected BPPV: Diagnostic criteria include 5-20 second latency, torsional upbeating nystagmus toward the affected ear, and symptoms resolving within 60 seconds. 2, 3
• Complete neurologic examination to identify focal deficits suggesting central pathology. 2

Imaging Decisions: When NOT to Image

No imaging is indicated for the following scenarios: 1, 3

• Brief episodic vertigo with typical BPPV features and positive Dix-Hallpike test
• Acute persistent vertigo with normal neurologic exam and HINTS examination consistent with peripheral vertigo (when performed by trained examiner)
• Nonspecific dizziness without vertigo, ataxia, or neurologic deficits (diagnostic yield <1% on CT, only 4% on MRI) 1

When Imaging IS Indicated

MRI head without IV contrast is recommended for: 1, 2

• High vascular risk patients (hypertension, age >50, diabetes, prior stroke) with acute vestibular syndrome, even with normal neurologic examination (11-25% may have posterior circulation stroke)
• Abnormal neurologic examination or HINTS examination suggesting central vertigo
• Unilateral or pulsatile tinnitus
• Asymmetric hearing loss
• Progressive neurologic symptoms

Critical pitfall: CT head has extremely low diagnostic yield (<1%) for isolated dizziness and misses most posterior circulation infarcts. MRI with diffusion-weighted imaging is far superior (4% diagnostic yield vs <1% for CT). 1, 3

Management Based on Etiology

For BPPV (Most Common Cause)

• Perform canalith repositioning procedures (Epley maneuver) immediately: 80% success after 1-3 treatments, 90-98% with repeat maneuvers. 2, 4
• Do NOT prescribe vestibular suppressant medications routinely—they don't address the underlying cause and delay central compensation. 4
• No imaging or laboratory testing needed for typical BPPV with positive Dix-Hallpike test. 3

For Medication-Induced Dizziness

• Review and adjust antihypertensives, sedatives, anticonvulsants, and psychotropic drugs—this is one of the most common and reversible causes. 3

For Vestibular Migraine

• Diagnostic criteria require episodic vestibular symptoms, migraine by International Headache Society criteria, and at least two migraine symptoms (headache, photophobia, phonophobia, aura) during at least two vertiginous episodes. 1
• Treatment includes migraine prophylaxis and lifestyle modifications. 3

For Persistent Symptoms

• Vestibular rehabilitation therapy is the primary intervention for persistent dizziness that fails initial treatment, significantly improving gait stability compared to medication alone. 4
• Reassess within 1 month to document resolution or persistence. 2, 4

Red Flags Requiring Urgent Evaluation

The following mandate immediate imaging and neurologic consultation: 2, 3

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

Critical pitfall: Normal neurologic examination does NOT exclude posterior circulation infarct—75-80% of patients with acute vestibular syndrome from posterior circulation infarct have no focal neurologic deficits. 3

Common Diagnostic Pitfalls to Avoid

• Don't rely on patient descriptions of "spinning" versus "lightheadedness"—focus on timing and triggers instead. 2, 3
• Don't assume BPPV without performing Dix-Hallpike—clinical diagnosis without positional testing is unreliable. 3
• Don't order routine imaging for isolated dizziness—diagnostic yield is extremely low and most findings are incidental. 1, 3
• Don't use CT when stroke is suspected—it misses most posterior circulation infarcts. 3
• Don't prescribe meclizine as primary treatment for BPPV—it only masks symptoms and delays compensation. 4