What is the best course of action for a 76-year-old female patient with a history of two episodes of non-positional dizziness, one of which was severe and accompanied by vomiting, over the past month, who presents for a well-check visit and has no prior medical evaluation for these symptoms?

Immediate Workup and Management for Recurrent Non-Positional Dizziness in Elderly Patient

This 76-year-old woman requires a Dix-Hallpike maneuver at today's visit to diagnose or exclude BPPV, followed by targeted evaluation for vestibular migraine, Ménière's disease, and medication-related causes, with urgent neuroimaging reserved only if red flags emerge. 1

Initial Diagnostic Approach

Perform the Dix-Hallpike maneuver bilaterally immediately during this visit. 1, 2 Despite the patient reporting symptoms are "not positional," BPPV remains the most common cause of episodic vertigo in elderly patients (36.3% of cases) and is present in 9% of elderly patients referred for geriatric evaluation—three-fourths of whom had fallen within the prior 3 months. 1 Patients often cannot reliably distinguish positional from non-positional triggers, making the examination more reliable than history alone. 1

Key Historical Details to Clarify

• Episode duration: Seconds suggest BPPV, minutes to hours suggest vestibular migraine or Ménière's disease, days to weeks suggest vestibular neuritis or stroke 1, 2
• Associated symptoms: Hearing loss, tinnitus, or aural fullness point to Ménière's disease 1, 2; headache, photophobia, or phonophobia suggest vestibular migraine 1
• Vascular risk factors: Age >50, hypertension, diabetes, atrial fibrillation, or prior stroke increase posterior circulation stroke risk to 11-25% even with normal neurologic exam 1
• Medication review: Antihypertensives, sedatives, anticonvulsants, and psychotropic drugs are leading reversible causes of chronic vestibular syndrome 1, 2

Physical Examination Priorities

Essential Maneuvers

Dix-Hallpike maneuver interpretation: 1, 2

• Peripheral (BPPV): Torsional and upbeating nystagmus with 5-20 second latency, crescendo-decrescendo pattern, fatigues with repeat testing, resolves within 60 seconds
• Central pathology: Immediate onset, persistent nystagmus, purely vertical without torsional component, downbeating nystagmus

Complete neurologic examination to identify focal deficits, as 75-80% of patients with posterior circulation infarct have NO focal neurologic deficits. 1 This is a critical pitfall—normal neurologic exam does NOT exclude stroke in acute vestibular syndrome.

Orthostatic vital signs to assess for medication-induced hypotension or volume depletion. 1

Assessment for nystagmus at rest without provocative maneuvers, which is a red flag for central pathology. 2

Imaging Decisions

When NOT to Image

No imaging is indicated if: 1

• Dix-Hallpike is positive with typical BPPV features
• Normal neurologic examination
• No red flags present
• CT head has <1% diagnostic yield for isolated dizziness and misses most posterior circulation infarcts 1

When Imaging IS Required

Order MRI brain without contrast immediately if ANY of these red flags are present: 1, 2

• Severe postural instability with falling
• New severe headache accompanying dizziness
• Any focal neurologic deficits
• Downbeating nystagmus on Dix-Hallpike without torsional component
• Purely vertical nystagmus without torsional component
• Baseline nystagmus present without provocative maneuvers
• Failure to respond to appropriate vestibular treatments
• Unilateral or pulsatile tinnitus
• Asymmetric hearing loss
• High vascular risk factors (even with normal exam, given 11-25% stroke risk) 1

MRI with diffusion-weighted imaging has 4% diagnostic yield versus <1% for CT and is essential for detecting posterior circulation infarcts. 1 Never substitute CT for MRI when stroke is suspected.

Management Algorithm

If Dix-Hallpike is Positive for BPPV

Perform Epley maneuver immediately with 80% success after 1-3 treatments and 90-98% success with repeat maneuvers. 1, 2 Do NOT prescribe vestibular suppressants for BPPV as they prevent central compensation. 2

Reassess within 1 month to document resolution or persistence. 1 Counsel about 50% recurrence risk over 5 years and fall risk (12-fold increase). 1, 3

If Dix-Hallpike is Negative

Evaluate for vestibular migraine: 1, 2

• Accounts for 14% of all vertigo cases, lifetime prevalence 3.2%
• Requires current or past migraine history
• Episodes lasting 5 minutes to 72 hours
• Migraine symptoms (photophobia, phonophobia, visual aura) during ≥50% of dizzy episodes

Evaluate for Ménière's disease: 1, 2

• Classic triad: episodic vertigo lasting hours, fluctuating sensorineural hearing loss, tinnitus, and aural fullness
• Key distinguishing feature: Fluctuating hearing loss that worsens over time (versus stable/absent hearing loss in vestibular migraine)
• Order audiogram if suspected

Medication review is mandatory as this is one of the most common and reversible causes. 1 Review all antihypertensives, sedatives, anticonvulsants, and psychotropic medications.

Screen for psychiatric symptoms (anxiety, panic disorder, depression) as these are common causes of chronic dizziness. 1

Critical Pitfalls to Avoid

• Do NOT rely on patient's description of "spinning" versus "lightheadedness"—focus on timing and triggers instead 1
• Do NOT assume normal neurologic exam excludes stroke—75-80% of posterior circulation infarcts have no focal deficits 1
• Do NOT order routine CT for isolated dizziness—it has <1% yield and misses posterior circulation infarcts 1
• Do NOT overlook vestibular migraine—it is extremely common but under-recognized, particularly in patients with migraine history 1, 2
• Do NOT forget fall risk assessment—dizziness increases fall risk 12-fold in elderly patients 1, 3

Specific Recommendations for This Patient

Given her age (76), two episodes over one month with one severe enough to cause vomiting, and morning onset pattern:

1. Perform Dix-Hallpike maneuver today despite "non-positional" history 1, 2
2. Document vascular risk factors (hypertension, diabetes, atrial fibrillation) as these mandate lower threshold for MRI even with normal exam 1
3. Complete medication review focusing on any recent changes or dose adjustments 1
4. Assess fall risk and counsel about home safety modifications 1, 3
5. Order MRI brain without contrast if she has high vascular risk factors OR any red flags, even with normal neurologic exam 1
6. Consider audiogram if any hearing symptoms to distinguish Ménière's from vestibular migraine 1, 2