What are the differential diagnoses and treatment options for an adult or geriatric patient with dizziness, considering their demographic, medical history of cardiovascular disease, neurological disorders, or inner ear problems, and potential contributing medications such as antihypertensives (blood pressure medications), sedatives, or antidepressants?

Differential Diagnoses for Dizziness

The differential diagnosis for dizziness must be categorized by timing and triggers—not the patient's subjective description—into four distinct syndromes: brief episodic vertigo (seconds to minutes), acute persistent vertigo (days to weeks), spontaneous episodic vertigo (minutes to hours), and chronic vestibular syndrome (weeks to months). 1

Brief Episodic Vertigo (Seconds to Minutes)

Benign Paroxysmal Positional Vertigo (BPPV) is the most common cause, accounting for 42% of peripheral vertigo cases, triggered by head position changes. 2 The Dix-Hallpike maneuver is the gold standard diagnostic test and should be performed in every patient with these symptoms. 1 Positive findings include torsional, upbeating nystagmus with 5-20 second latency, crescendo-decrescendo pattern that resolves within 60 seconds, and fatigability with repeat testing. 3

Orthostatic hypotension presents with brief lightheadedness upon standing, particularly in patients on antihypertensives. 3 Check orthostatic vital signs in all patients with brief episodic symptoms. 4

Acute Persistent Vertigo (Days to Weeks)

Vestibular neuritis accounts for 41% of peripheral vertigo cases, presenting with severe continuous vertigo, nausea, vomiting, and intolerance to head motion without hearing loss. 2

Labyrinthitis presents identically to vestibular neuritis but includes hearing loss. 2

Posterior circulation stroke is the critical central cause to exclude—approximately 25% of acute vestibular syndrome cases are cerebrovascular, rising to 75% in high vascular risk patients (age >50, hypertension, diabetes, atrial fibrillation, prior stroke). 2 The HINTS examination (Head Impulse, Nystagmus, Test of Skew) has 100% sensitivity for detecting stroke when performed by trained practitioners, superior to early MRI (46% sensitivity). 3

Spontaneous Episodic Vertigo (Minutes to Hours)

Vestibular migraine has a lifetime prevalence of 3.2% and accounts for up to 14% of vertigo cases, particularly common in young women. 2 Episodes can be short (<15 minutes) or prolonged (>24 hours), with photophobia, phonophobia, or visual aura during at least 50% of episodes. 2 Hearing loss is typically mild, absent, or stable—not fluctuating. 2

Ménière's disease presents with the classic triad: episodic vertigo lasting hours, fluctuating sensorineural hearing loss that worsens over time, tinnitus, and aural fullness. 2 This accounts for 10% of general practice vertigo cases and up to 43% in specialty settings. 2

Vertebrobasilar insufficiency causes episodes typically lasting less than 30 minutes without hearing loss, with severe postural instability, gaze-evoked nystagmus that doesn't fatigue, and may precede stroke by weeks or months. 2

Chronic Vestibular Syndrome (Weeks to Months)

Medication side effects are a leading reversible cause. 3 Review antihypertensives (particularly diuretics like HCTZ), sedatives, anticonvulsants (carbamazepine, phenytoin, primidone), and psychotropic drugs. 3, 2 Aminoglycosides like gentamicin cause irreversible vestibulotoxicity. 2

Anxiety, panic disorder, and depression are common causes of chronic nonspecific dizziness. 3 Screen for psychiatric symptoms in all chronic cases. 3

Posttraumatic vertigo persists chronically after head trauma with vertigo, disequilibrium, tinnitus, and headache. 3

Posterior fossa mass lesions present with progressive neurologic symptoms. 3

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Treatment Approach

BPPV Treatment

Perform the Epley maneuver (canalith repositioning) immediately for confirmed BPPV—80% success after 1-3 treatments, 90-98% with repeat maneuvers. 3 No imaging or medication is needed for typical BPPV. 1 Vestibular suppressants should not be prescribed as they prevent central compensation. 2

Vestibular Neuritis/Labyrinthitis

Use vestibular suppressants (anticholinergics, benzodiazepines) only briefly during the acute phase. 5 Refer for vestibular rehabilitation therapy, which significantly improves gait stability compared to medication alone, particularly beneficial for elderly patients or those with heightened fall risk. 3

Ménière's Disease

Initiate dietary sodium restriction and diuretics. 2, 5 Consider intratympanic dexamethasone or gentamicin for refractory cases. 6

Vestibular Migraine

Prescribe L-channel calcium channel antagonists, tricyclic antidepressants, or beta-blockers for prophylaxis. 5 Implement dietary modifications and lifestyle interventions. 2

Medication-Induced Dizziness

Discontinue or adjust offending medications—this is one of the most common and reversible causes. 3 For orthostatic hypotension from antihypertensives, consider alpha agonists, mineralocorticoids, or lifestyle changes if medication adjustment is insufficient. 6

Vertebrobasilar Insufficiency

Requires urgent neurology consultation and stroke prevention measures. 2

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Red Flags Requiring Urgent MRI Brain Without Contrast

• Focal neurological deficits (dysarthria, dysmetria, dysphagia, sensory/motor deficits, diplopia, Horner's syndrome) 2
• Sudden unilateral hearing loss 1
• Inability to stand or walk/severe postural instability with falling 1, 2
• Downbeating or purely vertical nystagmus without torsional component 1, 2
• Direction-changing nystagmus without head position changes 2
• Baseline nystagmus present without provocative maneuvers 2
• New severe headache 1
• Progressive neurologic symptoms 1
• Failure to respond to appropriate peripheral vertigo treatments 1, 2
• High vascular risk patients with acute vestibular syndrome, even with normal neurologic exam 1
• Unilateral or pulsatile tinnitus 3
• Asymmetric hearing loss 3

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Critical Pitfalls to Avoid

Do not rely on patient descriptions of "spinning" versus "lightheadedness"—focus exclusively on timing and triggers. 1, 3 This is the most common diagnostic error.

Do not skip the Dix-Hallpike maneuver—BPPV is the most common cause and is easily missed without this test. 1

Do not assume a normal neurologic exam excludes stroke—75-80% of patients with posterior circulation infarct from acute vestibular syndrome have no focal neurologic deficits. 3 High vascular risk patients require MRI even with normal exams. 1

Do not order CT instead of MRI when stroke is suspected—CT has <1% diagnostic yield for isolated dizziness and misses most posterior circulation infarcts, while MRI has 4% diagnostic yield. 3

Do not order imaging for straightforward BPPV with positive Dix-Hallpike and no red flags—this delays treatment unnecessarily. 1

Do not overlook vestibular migraine—it is extremely common but under-recognized. 1 Look for migraine features and distinguish from Ménière's by the absence of fluctuating hearing loss. 2

Do not forget medication review—this is one of the most common reversible causes of chronic dizziness. 1, 3

Do not miss cerebellar stroke—approximately 10% of cerebellar strokes present similar to peripheral vestibular disorders. 2