What is the appropriate workup and management for a previously healthy adult patient presenting with dizziness?

Workup for Dizziness in Previously Healthy Adults

Focus your initial evaluation on timing and triggers rather than the patient's vague description of "dizziness"—this approach categorizes patients into specific vestibular syndromes that directly guide management and determine whether imaging is needed. 1, 2

Initial History: Critical Elements

Ask these specific questions to categorize the dizziness:

• Duration of episodes: Seconds (<1 minute) suggests BPPV; hours suggests Ménière's or vestibular migraine; days to weeks suggests acute vestibular syndrome 1, 2
• Triggers: Head position changes strongly suggest BPPV; no trigger with spontaneous onset suggests vestibular neuritis or stroke 1, 2
• Associated symptoms:
  • Hearing loss, tinnitus, or aural fullness → Ménière's disease 1, 2
  • Headache with photophobia/phonophobia → vestibular migraine 1
  • Focal neurologic symptoms (diplopia, dysarthria, numbness, weakness) → central cause requiring urgent imaging 1, 2

Common pitfall: Do NOT rely on whether patients describe "spinning" versus "lightheadedness"—this distinction is unreliable and misleading 1

Physical Examination: Essential Maneuvers

Perform these specific tests based on symptom timing:

For Brief Episodic Symptoms (Seconds to Minutes)

• Dix-Hallpike maneuver: Gold standard for BPPV diagnosis 1, 2, 3
  • Positive findings: 5-20 second latency, torsional upbeating nystagmus toward affected ear, symptoms resolve within 60 seconds 1, 2
  • If positive with typical features: NO imaging or lab testing needed 1, 2, 3

For Acute Persistent Symptoms (Days to Weeks)

• Complete neurologic examination: Check for focal deficits, ataxia, dysmetria 1, 2
• HINTS examination (Head Impulse, Nystagmus, Test of Skew) if trained: 100% sensitivity for stroke when performed by experts, but unreliable by non-experts 1, 4
  • Normal HIT (corrective saccade present) + direction-changing nystagmus + skew deviation = central cause 1, 4

For All Patients

• Observe for spontaneous nystagmus: Bidirectional, vertical, or pure torsional nystagmus indicates central pathology 1, 2
• Orthostatic vital signs: Rule out presyncope 5
• Medication review: Antihypertensives, sedatives, anticonvulsants are leading reversible causes of chronic dizziness 1

Laboratory Testing

Routine laboratory testing is NOT indicated for isolated dizziness with normal vital signs and non-contributory examination 6

Order selective testing only when history/examination suggests:

• Hypoglycemia (diabetes history) 6
• Electrolyte abnormalities (vomiting, diarrhea, dehydration) 6
• Thyroid disease (affective symptoms) 6

Critical evidence: Multiple studies show routine lab panels have false positives 8 times more frequent than true positives (1.8%) in psychiatric/dizziness presentations 6

Imaging Decisions: When NOT to Image

Do NOT order imaging for: 1, 2, 3

• Brief episodic vertigo with positive Dix-Hallpike and typical BPPV features
• Acute persistent vertigo with normal neurologic exam AND peripheral HINTS findings (by trained examiner)
• Chronic nonspecific dizziness without focal neurologic signs

Critical pitfall: CT head has <1% diagnostic yield for isolated dizziness and misses most posterior circulation strokes—it should NOT be used as a screening tool 1, 2

Imaging Decisions: When Imaging IS Required

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

Red Flags Requiring Urgent MRI:

• Focal neurologic deficits on examination
• Abnormal HINTS examination suggesting central cause
• New severe headache accompanying dizziness
• Inability to stand or walk
• Downbeating or direction-changing nystagmus
• Sudden hearing loss
• Progressive neurologic symptoms

High Vascular Risk Patients:

• Age >50 with hypertension, diabetes, prior stroke, or atrial fibrillation presenting with acute vestibular syndrome—even with normal neurologic exam 1, 2
• Rationale: 11-25% of high-risk patients have posterior circulation stroke despite normal examination 1

Specific Scenarios:

• Unilateral or pulsatile tinnitus (evaluate for vascular malformation, vestibular schwannoma) 1, 2
• Asymmetric hearing loss (rule out acoustic neuroma) 1, 2

Why MRI over CT: MRI with diffusion-weighted imaging has 4% diagnostic yield versus <1% for CT, and CT sensitivity is only 20-40% for posterior circulation infarcts 1, 2

Management Based on Diagnosis

BPPV (Most Common)

• Immediate treatment: Epley maneuver with 80% success after 1-3 treatments, 90-98% with repeat procedures 1, 2, 3
• No medications needed 1
• Counsel on 10-18% recurrence risk at one year, fall prevention 2

Vestibular Neuritis/Labyrinthitis

• Supportive care, vestibular rehabilitation therapy 1, 5
• Short-course vestibular suppressants only if severe (delays central compensation) 5

Persistent Dizziness After Initial Treatment

• Vestibular rehabilitation therapy: Significantly improves gait stability, particularly in elderly or high fall-risk patients 1, 2

Critical Pitfalls to Avoid

1. Assuming normal neurologic exam excludes stroke: 75-80% of posterior circulation stroke patients have no focal deficits 1
2. Ordering CTA head/neck routinely: Only 3% diagnostic yield, 14% sensitivity—not useful for isolated dizziness 1
3. Using CT instead of MRI for suspected stroke: CT misses most posterior circulation infarcts 1, 2
4. Failing to perform Dix-Hallpike: Missing this simple bedside test leads to unnecessary imaging and delayed treatment 1, 2, 3
5. Over-relying on HINTS by non-experts: Sensitivity drops significantly when not performed by trained practitioners 1, 4