What is the appropriate initial evaluation and treatment for a patient presenting with dizziness or vertigo, considering their past medical history and potential underlying causes such as Benign Paroxysmal Positional Vertigo (BPPV) or vestibular migraine?

Initial Evaluation and Treatment of Dizziness or Vertigo

Classify the patient by timing and triggers—not by their subjective description of "dizziness"—to distinguish benign peripheral causes from dangerous central pathology like stroke. 1, 2

Step 1: Categorize by Vestibular Syndrome

Determine which of three syndromes applies based on duration and triggers 1, 2:

Triggered Episodic Vestibular Syndrome (Seconds to <1 Minute)

• Episodes last <1 minute and are triggered by specific head position changes 1, 2
• Most commonly Benign Paroxysmal Positional Vertigo (BPPV), accounting for 42% of peripheral vertigo cases 3
• Perform Dix-Hallpike maneuver immediately—this is the gold standard diagnostic test 4, 1
• Positive findings: 5-20 second latency, torsional upbeating nystagmus toward affected ear, crescendo-decrescendo pattern resolving within 60 seconds 1, 3

Acute Vestibular Syndrome (Days to Weeks, Constant)

• Continuous vertigo lasting days to weeks with nausea, vomiting, and intolerance to head motion 1, 2
• Differential includes vestibular neuritis (41% of cases), labyrinthitis, or posterior circulation stroke 3, 5
• Perform HINTS examination (Head Impulse, Nystagmus, Test of Skew) if trained—100% sensitive for stroke vs 46% for early MRI 1, 2
• Critical caveat: 75-80% of posterior circulation stroke patients have NO focal neurologic deficits, so normal neuro exam does not exclude stroke 1

Spontaneous Episodic Vestibular Syndrome (Minutes to Hours, No Trigger)

• Episodes last minutes to hours without positional triggers 1, 2
• Consider vestibular migraine if headache, photophobia, phonophobia present 1, 3
• Consider Ménière's disease if fluctuating hearing loss, tinnitus, aural fullness 1, 2
• Consider vertebrobasilar TIA if episodes <30 minutes in high vascular risk patients 3

Step 2: Focused History—Essential Details

Timing Details

• Seconds: BPPV 1, 2
• Minutes to hours: Vestibular migraine, Ménière's disease 1, 2
• Days to weeks: Vestibular neuritis, stroke 1, 2

Specific Triggers

• Head position changes: BPPV 1, 2
• Pressure changes (Valsalva, coughing): Superior canal dehiscence 1
• No trigger: Vestibular neuritis, stroke 1, 2

Associated Symptoms

• Hearing loss + tinnitus + aural fullness: Ménière's disease 1, 2
• Headache + photophobia + phonophobia: Vestibular migraine 1, 3
• Any focal neurologic symptoms: Central cause requiring urgent imaging 1, 2

Medication Review

• Antihypertensives, sedatives, anticonvulsants, psychotropic drugs are leading causes of chronic dizziness 1
• Aminoglycosides cause irreversible vestibular toxicity 3

Fall Risk Assessment

• Ask: "Have you fallen in the past year? How many times?" 1
• Dizziness increases fall risk 12-fold in elderly patients 1
• BPPV present in 9% of elderly patients, with three-fourths having fallen within prior 3 months 1

Step 3: Physical Examination—Specific Maneuvers

Dix-Hallpike Maneuver (for Triggered Episodes)

• Mandatory for suspected BPPV—do not skip this 4, 1
• Peripheral (BPPV) findings: Latency 5-20 seconds, torsional upbeating nystagmus, fatigues with repeat testing, resolves <60 seconds 1, 3
• Central findings (RED FLAG): Immediate onset, purely vertical nystagmus without torsional component, does not fatigue, persists beyond 60 seconds 1, 3

HINTS Examination (for Acute Persistent Vertigo)

• Only perform if trained—unreliable when performed by non-experts 1
• Head Impulse: Abnormal (corrective saccade) = peripheral; Normal = central 1, 2
• Nystagmus: Unidirectional horizontal = peripheral; Direction-changing or pure vertical = central 1, 3
• Test of Skew: Vertical misalignment = central 1, 2

Nystagmus Characteristics

• Peripheral: Horizontal with rotatory component, unidirectional, suppressed by visual fixation, fatigable 3
• Central: Pure vertical, direction-changing, NOT suppressed by visual fixation, NOT fatigable 3

Neurologic Examination

• Complete cranial nerve testing, cerebellar testing (finger-to-nose, heel-to-shin), gait assessment 1, 2
• Orthostatic vital signs to assess for presyncope 5, 6

Step 4: Imaging Decisions—When NOT to Image

No imaging is indicated for 1, 2:

• Brief episodic vertigo with typical BPPV features and positive Dix-Hallpike test
• Acute persistent vertigo with normal neurologic exam AND HINTS consistent with peripheral vertigo by trained examiner
• Nonspecific dizziness without vertigo, ataxia, or neurologic deficits

Critical pitfall: CT head has <1% diagnostic yield for isolated dizziness and misses most posterior circulation infarcts 1, 2

Step 5: Imaging Decisions—When Imaging IS Required

Order MRI brain without contrast (NOT CT) for 1, 2:

• Abnormal neurologic examination
• HINTS examination suggesting central cause
• High vascular risk patients (age >50, hypertension, diabetes, prior stroke) with acute vestibular syndrome—even with normal neuro exam, as 11-25% have posterior circulation stroke 1
• Unilateral or pulsatile tinnitus
• Asymmetric hearing loss
• Progressive neurologic symptoms
• New severe headache with vertigo

Why MRI, not CT: MRI has 4% diagnostic yield vs <1% for CT; CT sensitivity only 20-40% for posterior circulation infarcts 1

Step 6: RED FLAGS Requiring Urgent Evaluation

Immediate imaging and neurology consultation for 4, 1, 3:

• Focal neurological deficits (dysarthria, dysmetria, dysphagia, diplopia, limb weakness)
• Sudden hearing loss
• Inability to stand or walk (severe postural instability)
• Downbeating nystagmus or other central nystagmus patterns
• New severe headache
• Failure to respond to appropriate vestibular treatments
• Direction-changing nystagmus without head position changes

Step 7: Treatment Based on Diagnosis

BPPV (Most Common)

• Perform canalith repositioning procedure (Epley maneuver) immediately—80% success after 1-3 treatments, 90-98% with repeat maneuvers 4, 1
• Do NOT prescribe vestibular suppressants (meclizine, diazepam)—they prevent central compensation and delay recovery 3
• No imaging or laboratory testing needed for typical BPPV with positive Dix-Hallpike 1, 2
• Reassess within one month to document resolution 1

Treatment Failure in BPPV

• If symptoms persist after 2-3 Epley maneuvers, reevaluate for 4:
  • Persistent BPPV in different semicircular canal
  • Underlying peripheral vestibular disorder
  • CNS disorder masquerading as BPPV (3% of treatment failures)—obtain MRI brain and posterior fossa 4

Vestibular Neuritis/Labyrinthitis

• Vestibular suppressants (meclizine 25mg TID) for acute phase only (first 2-3 days) 6
• Steroids may be beneficial if started within 72 hours 6
• Vestibular rehabilitation therapy as primary intervention once acute phase resolves 1, 6

Vestibular Migraine

• Migraine prophylaxis (topiramate, propranolol) and lifestyle modifications 1, 2
• Dietary triggers, sleep hygiene, stress management 3

Ménière's Disease

• Salt restriction (<2g sodium/day) and diuretics (hydrochlorothiazide) 1, 2
• Intratympanic dexamethasone or gentamicin for refractory cases 1, 5

Vestibular Rehabilitation Therapy

• Primary intervention for persistent dizziness failing initial treatment 1
• Significantly improves gait stability compared to medication alone 1
• Particularly beneficial for elderly patients, those with CNS disorders, or heightened fall risk 1
• Includes habituation exercises, gaze stabilization, balance retraining, fall prevention 1

Step 8: Patient Counseling

Counsel all patients regarding 4, 1:

• BPPV recurrence rate 5-13.5%—return promptly if symptoms recur for repeat repositioning 4
• Fall risk—home safety assessment, avoid driving during acute episodes 1
• Activity restrictions until symptoms resolve 1
• Home supervision if elderly and frail 1

Common Pitfalls to Avoid

• Do NOT rely on patient's description of "spinning" vs "lightheadedness"—focus on timing and triggers instead 1
• Do NOT assume normal neurologic exam excludes stroke—75-80% of posterior circulation infarcts have no focal deficits 1
• Do NOT order CT when stroke suspected—CT misses most posterior circulation infarcts; order MRI 1, 2
• Do NOT order routine imaging for isolated dizziness—very low yield, most findings incidental 1
• Do NOT order vestibular testing or imaging for straightforward BPPV with positive Dix-Hallpike—unnecessary and delays treatment 1
• Do NOT overlook medication side effects—leading reversible cause of chronic dizziness 1
• Do NOT miss concurrent vestibular disorders—BPPV can coexist with Ménière's disease or vestibular neuritis 3