What are the appropriate diagnostic tests and treatment options for a patient presenting with vertigo?

Diagnostic Testing and Treatment for Vertigo

For patients presenting with vertigo, the diagnostic approach should be guided by timing and triggers rather than subjective symptom descriptions, with imaging reserved only for specific high-risk scenarios, and treatment tailored to the underlying vestibular syndrome identified through targeted physical examination maneuvers. 1

Initial Clinical Classification

The first step is categorizing vertigo into one of four vestibular syndromes based on temporal patterns 1, 2:

• Triggered Episodic Vertigo (seconds to <1 minute): Brief episodes provoked by specific head position changes, most commonly BPPV 1, 3
• Spontaneous Episodic Vertigo (minutes to hours): Unprovoked episodes suggesting Ménière's disease, vestibular migraine, or vertebrobasilar insufficiency 3
• Acute Vestibular Syndrome (days to weeks): Continuous severe vertigo suggesting vestibular neuritis, labyrinthitis, or posterior circulation stroke 1, 3
• Chronic Vestibular Syndrome (weeks to months): Persistent symptoms often due to medication effects, anxiety disorders, or rarely posterior fossa masses 1, 2

Essential Physical Examination Maneuvers

For Triggered Episodic Vertigo (Suspected BPPV)

Perform the Dix-Hallpike maneuver as the gold standard diagnostic test 1, 2. Diagnostic criteria include 1:

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

If Dix-Hallpike is negative but history suggests BPPV, perform the Supine Roll Test to diagnose lateral canal BPPV (10-15% of cases) 3.

For Acute Vestibular Syndrome

Perform the HINTS examination (Head Impulse, Nystagmus, Test of Skew) when evaluating acute persistent vertigo 1, 2. This has 92.9% sensitivity and 83.4% specificity for central causes when performed by trained clinicians, and 100% sensitivity for detecting stroke—superior to early MRI (46% sensitivity) 1, 4.

Critical caveat: HINTS reliability drops significantly when performed by non-experts 1, 2.

Red Flags Requiring Urgent Evaluation

Immediate imaging and neurologic consultation are mandatory for 1, 2:

• Focal neurological deficits (cranial nerve abnormalities, limb weakness)
• Sudden hearing loss
• Inability to stand or walk (severe postural instability)
• New severe headache accompanying dizziness
• Downbeating nystagmus or other central nystagmus patterns
• Failure to respond to appropriate vestibular treatments

Imaging Guidelines: When NOT to Image

Do not order imaging for 5, 1, 2:

• 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 (by trained examiner)
• Straightforward BPPV meeting diagnostic criteria with no additional concerning features 5, 1

Routine neuroimaging is not justified for BPPV as it does not improve diagnostic accuracy and adds unnecessary cost and radiation exposure 5.

Imaging Guidelines: When TO Image

MRI Brain Without Contrast (First-Line)

Order MRI brain without IV contrast for 5, 1, 2:

• Persistent vertigo with abnormal neurologic examination
• HINTS examination suggesting central cause
• High vascular risk patients (age >50, hypertension, diabetes, atrial fibrillation, prior stroke) with acute vestibular syndrome, even with normal neurologic exam—11-25% may have posterior circulation stroke 2
• Progressive neurologic symptoms
• Unilateral or pulsatile tinnitus
• Asymmetric hearing loss

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

MRI Head and Internal Auditory Canal With and Without Contrast

Consider for 5, 2:

• Episodic vertigo with associated hearing loss or aural fullness (to exclude vestibular schwannoma in suspected Ménière's disease)
• Persistent vertigo with neurologic symptoms

CT Temporal Bone Without Contrast

Appropriate for 5:

• Episodic peripheral vertigo with auditory symptoms when structural inner ear pathology is suspected

Avoid CT Head

CT head has extremely low diagnostic yield (<1%) for isolated dizziness and misses most posterior circulation infarcts 1, 2. CT sensitivity is only 20-40% for detecting causative pathology in vertigo 2.

MRA Head and Neck

Consider only for 5:

• Episodic vertigo that cannot be confidently categorized as peripheral, to detect vertebrobasilar insufficiency
• Pulsatile tinnitus (to evaluate for vascular malformations, arterial dissection) 2

Vestibular Function Testing

Do not routinely order vestibular function testing for patients meeting clinical criteria for BPPV 5. Testing adds little diagnostic accuracy, significant cost, and does not alter management in the vast majority of cases 5.

Vestibular testing may be appropriate only when 5:

• The diagnosis remains unclear after history and examination
• Dix-Hallpike findings are equivocal
• Multiple concurrent peripheral vestibular disorders are suspected
• Patient remains symptomatic following appropriate treatment

Treatment Based on Diagnosis

BPPV (Most Common Cause—36.3% of Vertigo Cases)

Perform canalith repositioning procedures (Epley maneuver) immediately 1, 2. Success rates are 1, 2:

• 80% after 1-3 treatments
• 90-98% with repeat maneuvers

No medications are necessary for typical BPPV 1, 2. Meclizine is FDA-approved for vertigo associated with vestibular system diseases at 25-100 mg daily in divided doses 6, but is not first-line for BPPV.

Counsel patients about 1:

• Recurrence risk: 10-18% at one year, up to 36% long-term
• Fall risk (particularly in elderly—dizziness increases fall risk 12-fold) 2
• Return promptly if symptoms recur for repeat repositioning

Vestibular Neuritis/Labyrinthitis

Initial management includes 7:

• Vestibular suppressant medication (meclizine 25-100 mg daily) for acute phase only 6
• Followed by vestibular rehabilitation therapy (not prolonged medication use)

Ménière's Disease

Treatment approach 7:

• Low-salt diet
• Diuretics
• Consider intratympanic treatments for refractory cases

Vestibular Migraine

Management includes 7:

• Dietary modifications
• Tricyclic antidepressant
• Beta blocker or calcium channel blocker

Persistent Dizziness After Initial Treatment

Refer for vestibular rehabilitation therapy, which significantly improves gait stability compared to medication alone and is particularly beneficial for elderly patients or those with heightened fall risk 1, 2.

Common Pitfalls to Avoid

• Do not rely on patient's description of "spinning" versus "lightheadedness"—focus on timing and triggers instead 1, 2
• Do not assume normal neurologic exam excludes stroke—75-80% of patients with acute vestibular syndrome from posterior circulation infarct have no focal neurologic deficits 1, 2
• Do not overuse imaging in patients with clear peripheral causes and positive Dix-Hallpike testing 5, 1
• Do not use CT instead of MRI when stroke is suspected—CT misses many posterior circulation infarcts 1, 2
• Do not perform HINTS examination if you are not trained—reliability drops significantly with non-expert examiners 1, 2
• Do not order routine vestibular function testing for straightforward BPPV—it delays treatment without adding diagnostic value 5