What is the best approach to evaluating and managing dizziness in patients with varying ages and medical histories, such as cardiovascular disease or migraines?

Approach to Dizziness

Prioritize Timing and Triggers Over Symptom Description

The most critical first step is to categorize dizziness by timing and triggers rather than relying on the patient's subjective description of "spinning" versus "lightheadedness," which has poor diagnostic value. 1, 2, 3

The American Academy of Otolaryngology-Head and Neck Surgery recommends classifying patients into four distinct categories based on temporal patterns 1, 2:

• Brief episodic vertigo (seconds to <1 minute): Triggered by head position changes, strongly suggests BPPV 1, 2, 3
• Acute persistent vertigo (days to weeks): Constant symptoms with nausea/vomiting suggest vestibular neuritis, labyrinthitis, or posterior circulation stroke 1, 2
• Spontaneous episodic vertigo (minutes to hours): No positional trigger suggests vestibular migraine or Ménière's disease 1, 2, 3
• Chronic dizziness (weeks to months): Persistent symptoms suggest medication side effects, anxiety/panic disorder, or posttraumatic vertigo 1, 2

Critical Associated Symptoms to Elicit

Focus your history on specific red flags and diagnostic clues rather than vague symptom quality 1, 3:

• Hearing loss, tinnitus, and aural fullness point to Ménière's disease 4, 1, 2
• Headache, photophobia, and phonophobia strongly suggest vestibular migraine 1, 2, 3
• Focal neurological symptoms (dysarthria, diplopia, numbness, weakness, dysphagia, Horner's syndrome) are red flags for central pathology requiring urgent imaging 1, 2, 3

Essential Physical Examination Maneuvers

The Dix-Hallpike maneuver is the gold standard for diagnosing BPPV and should be performed in every patient with brief episodic dizziness triggered by position changes 1, 2, 3. Positive findings include:

• Latency period of 5-20 seconds before symptoms begin 2, 3
• Torsional, upbeating nystagmus toward the affected ear 2, 3
• Vertigo and nystagmus that increase then resolve within 60 seconds 2, 3

For acute persistent vertigo, the HINTS examination (Head-Impulse, Nystagmus, Test of Skew) has 100% sensitivity for detecting stroke when performed by trained practitioners 1, 2, though reliability drops significantly when performed by non-experts 2.

Perform a thorough neurologic exam including cranial nerve testing, cerebellar testing, gait assessment, and observation for spontaneous nystagmus 1.

Age-Specific and Comorbidity Considerations

Cardiovascular Disease Patients

High vascular risk patients (age >50, hypertension, diabetes, atrial fibrillation, prior stroke) with acute vestibular syndrome require MRI brain without contrast even with normal neurologic examination, as 11-25% may have posterior circulation stroke 2.

Migraine History

Vestibular migraine is extremely common and often under-recognized, accounting for 14% of all vertigo cases 3. Essential questions include:

• Current or past migraine history and family history of migraine 1
• Motion intolerance as a trigger 1
• Photophobia, phonophobia, or visual aura during vertigo episodes 1
• Episodes lasting 5 minutes to 72 hours with migraine features during ≥50% of episodes 3

When both Ménière's disease and vestibular migraine are possible, 35% of Ménière's patients also meet criteria for vestibular migraine 4. The key distinguishing feature is fluctuating hearing loss in Ménière's versus stable/absent hearing loss in vestibular migraine 1.

Elderly Patients

BPPV accounts for 36.3% of positional dizziness in older adults and is present in 9% of elderly patients referred for geriatric evaluation—three-fourths of whom had fallen within the prior 3 months 2. Dizziness increases fall risk 12-fold in elderly patients 2.

Document the number of falls in the past year, circumstances, and injuries sustained 2. Age-related physiological changes increase vulnerability, including reduced baroreceptor response and diminished heart rate response to orthostatic stress 2.

Red Flags Requiring Urgent Neuroimaging

Order MRI brain without contrast (NOT CT) immediately for 1, 2, 3:

• Focal neurological deficits on examination
• Sudden unilateral hearing loss
• Inability to stand or walk independently
• Downbeating or other central nystagmus patterns
• New severe headache accompanying dizziness
• Progressive neurologic symptoms
• Unilateral or pulsatile tinnitus with asymmetric hearing loss

CT head should never be used instead of MRI when stroke is suspected, as it has only 20-40% sensitivity for posterior circulation infarcts and misses most causative pathology 1, 2. MRI with diffusion-weighted imaging has 4% diagnostic yield versus <1% for CT 2.

When NOT to Image

Do not order imaging for 1, 2:

• Straightforward BPPV with positive Dix-Hallpike test and no additional concerning features
• Acute persistent vertigo with normal neurologic exam and HINTS examination consistent with peripheral vertigo by a trained examiner
• Nonspecific dizziness without vertigo, ataxia, or neurologic deficits

Routine imaging for isolated dizziness has extremely low yield (<1%) and most findings are incidental 2.

Treatment Based on Diagnosis

BPPV (Most Common Cause - 42% of Cases)

Canalith repositioning procedures (Epley maneuver) are first-line treatment with 80% success after 1-3 treatments and 90-98% success after repeat maneuvers 1, 2, 3. No medications or imaging are needed for typical cases 1, 2.

Reassess within one month to document resolution or persistence, and counsel about recurrence risk, fall risk, and the importance of returning promptly if symptoms recur 2.

Vestibular Migraine (14% of Cases)

Migraine prophylaxis and lifestyle modifications are essential 1, 3. Adequate clinical trials of abortive or prophylactic medicines in vestibular migraine are not available, so lack of response to typical migraine medicines does not rule out the diagnosis 4.

Ménière's Disease

Obtain an audiogram to document low-to-mid frequency sensorineural hearing loss 4, 3. When uncertainty exists between vestibular migraine and Ménière's disease, proceed through noninvasive therapeutic trials prior to any surgical or inner ear ablative interventions 4. Destructive interventions should be reserved for those with severe progressive hearing loss or lack of usable hearing 4.

Vestibular Neuritis

Initiate vestibular rehabilitation therapy as soon as possible 1. This is the primary intervention for persistent dizziness that has failed initial treatment and significantly improves gait stability compared to medication alone 2.

Chronic Dizziness

Medication review is essential and represents a leading reversible cause of chronic vestibular syndrome 2. Review antihypertensives, sedatives, anticonvulsants, and psychotropic drugs 2.

Screen for psychiatric symptoms (anxiety, panic disorder, depression), which are common causes of chronic dizziness accounting for 10-25% of cases 2, 5.

Critical Pitfalls to Avoid

• Assuming normal neurologic exam excludes stroke: 75-80% of posterior circulation strokes have no focal deficits 1, 2
• Skipping the Dix-Hallpike maneuver when indicated—it provides more diagnostic value than any imaging study 3
• Ordering imaging for straightforward BPPV, which delays treatment unnecessarily 1
• Overlooking vestibular migraine, which is extremely common but under-recognized 1
• Using CT instead of MRI when stroke is suspected 1, 2
• Relying on patient's description of symptom quality rather than timing and triggers 1, 3