Early Morning Vertigo in a 60-Year-Old with Diabetes, Hypertension, and Ischemic Heart Disease
The most critical first step is to determine whether this represents benign positional vertigo (BPPV) versus a posterior circulation stroke, as this patient's vascular risk factors place them in the high-risk category where 11-25% of acute vestibular presentations may represent stroke even with a normal neurologic examination. 1
Immediate Assessment Priority
This patient requires urgent evaluation for posterior circulation stroke given their age >50 and multiple vascular risk factors (diabetes, hypertension, ischemic heart disease). 1, 2 Even if the neurologic examination appears normal, 75-80% of patients with posterior circulation infarction present without focal neurologic deficits. 1
Critical History Elements to Obtain
- Duration of vertigo episodes: Seconds-only duration suggests BPPV, while minutes to hours suggests stroke/TIA or vestibular migraine 1, 3
- Timing specificity: Does vertigo occur specifically upon getting out of bed in the morning, or is it present continuously? 1
- Triggers: Head position changes strongly suggest BPPV 1, 4
- Associated symptoms requiring immediate imaging: New severe headache, sudden hearing loss, inability to stand or walk 1
Essential Physical Examination
Perform the Dix-Hallpike maneuver immediately to diagnose BPPV, which is the most common cause of positional vertigo (42% of peripheral vertigo cases). 1 A positive test shows:
- 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 1
If trained, perform the HINTS examination (Head-Impulse, Nystagmus, Test of Skew), which has 100% sensitivity for detecting stroke versus only 46% for early MRI. 1 However, this examination is less reliable when performed by non-experts. 1
Check orthostatic vital signs: Measure blood pressure and heart rate supine, then at 1 and 3 minutes after standing. 5 This patient's antihypertensive medications may cause orthostatic hypotension (systolic BP drop ≥20 mmHg or diastolic drop ≥10 mmHg), particularly problematic in the morning. 5
Imaging Decision Algorithm
DO NOT image if:
- Positive Dix-Hallpike test consistent with BPPV
- Normal neurologic examination
- No red flag symptoms 1
MUST obtain MRI brain without contrast if:
- High vascular risk (which this patient has) with acute vestibular syndrome, even with normal neurologic exam 1
- Abnormal neurologic examination 1
- HINTS examination suggesting central cause 1
- Any red flags: new severe headache, sudden hearing loss, inability to stand/walk, focal neurologic deficits 1
Never rely on CT imaging for suspected stroke in isolated vertigo—it has <1% diagnostic yield and misses most posterior circulation infarcts. 1 MRI with diffusion-weighted imaging is far superior (4% diagnostic yield vs <1% for CT). 1
Treatment Based on Diagnosis
If BPPV is Confirmed:
Perform canalith repositioning procedures (Epley maneuver) immediately as first-line treatment, with 80% success after 1-3 treatments and 90-98% success with repeat maneuvers. 1 No medications are necessary for typical BPPV. 1, 6
Meclizine 25-100 mg daily in divided doses may be used for symptomatic relief of vertigo associated with vestibular system diseases, though it is not first-line for BPPV. 6 Important warnings: causes drowsiness (caution with driving/machinery) and has anticholinergic effects (use carefully with history of glaucoma or prostate enlargement). 6
If Medication-Induced:
Review all medications systematically, as antihypertensives (diuretics, β-blockers, calcium channel blockers, ACE inhibitors), along with any sedatives or psychotropic drugs, commonly cause dizziness. 1, 3 This is a leading reversible cause of chronic vestibular symptoms. 1
If Orthostatic Hypotension:
- Adjust antihypertensive timing (avoid taking all medications at once in the morning)
- Increase fluid and salt intake if not contraindicated by heart failure
- Compression stockings
- Gradual position changes 5
If Vestibular Rehabilitation Needed:
Refer for vestibular rehabilitation therapy if symptoms persist despite initial treatment, particularly important in elderly patients or those with heightened fall risk. 1 This significantly improves gait stability compared to medication alone. 1
Critical Pitfalls to Avoid
- Never assume normal neurologic exam excludes stroke in this high-risk patient—up to 80% of stroke patients with acute vestibular syndrome have no focal neurologic signs 1, 3
- Do not order routine CT imaging—it misses most posterior circulation infarcts 1
- Do not overlook medication side effects as a reversible cause 1, 3
- Do not ignore fall risk—dizziness increases fall risk 12-fold in elderly patients 1, 3
Specific Considerations for This Patient's Comorbidities
Diabetes and hypertension management must be optimized as these are independent risk factors for both stroke and autonomic dysfunction causing orthostatic symptoms. 7 Blood pressure should be treated to target <130/80 mmHg with ACE inhibitors or ARBs as first-line agents. 7
Monitor for hypoglycemia, as this can present with dizziness and is the most frequently identified unexpected abnormality in elderly patients with dizziness. 1
Age-related physiological changes in this 60-year-old include reduced baroreceptor response, diminished heart rate response to orthostatic stress, and autonomic dysfunction, all predisposing to morning dizziness. 3