Dizziness Workup and Management
Begin by categorizing dizziness based on timing and triggers rather than the patient's subjective description, as this approach is far more diagnostically valuable and guides targeted physical examination and treatment. 1
Initial Clinical Categorization
The first step is to classify dizziness into one of four temporal patterns, as this determines your entire diagnostic and management pathway 1, 2:
- Brief episodic vertigo (seconds to minutes): Triggered by head position changes, strongly suggests BPPV 1
- Acute vestibular syndrome (days to weeks): Constant symptoms with nausea/vomiting, suggests 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, 3
- Chronic vestibular syndrome (weeks to months): Persistent symptoms, suggests medication side effects, anxiety/panic disorder, or posttraumatic vertigo 1
Critical History Elements
Focus your history on these specific diagnostic details rather than vague symptom descriptions 1, 2:
Associated Symptoms
- Hearing loss, tinnitus, aural fullness: Points to Ménière's disease (fluctuating hearing loss is the key distinguishing feature) 1, 3
- Headache, photophobia, phonophobia: Strongly suggests vestibular migraine, which accounts for 14% of all vertigo cases and is often under-recognized in young patients 1, 3
- Focal neurologic symptoms (dysarthria, diplopia, numbness, weakness): Red flags for central pathology requiring urgent imaging 3, 2
Vascular Risk Factors
Document age >50, hypertension, atrial fibrillation, diabetes, and prior stroke, as 11-25% of high vascular risk patients with acute vestibular syndrome have posterior circulation stroke even with normal neurologic examination 1
Medication Review
This is a leading reversible cause of chronic dizziness—specifically review antihypertensives, sedatives, anticonvulsants, and psychotropic drugs 1
Fall History
Dizziness increases fall risk 12-fold in elderly patients; document number of falls in the past year, circumstances, and injuries sustained 1
Physical Examination
Essential Maneuvers
Dix-Hallpike Maneuver: This is the gold standard for diagnosing BPPV and should be performed in every patient with brief episodic dizziness triggered by position changes 1, 3. Diagnostic criteria include:
- 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
HINTS Examination (Head-Impulse, Nystagmus, Test of Skew): For acute vestibular syndrome, this examination has 100% sensitivity for detecting posterior circulation stroke when performed by trained practitioners—superior to early MRI which has only 46% sensitivity 1, 2. However, when performed by non-experts, results are less reliable 1.
Critical Pitfall: 75-80% of patients with posterior circulation stroke have NO focal neurologic deficits, so a normal neurologic exam does NOT exclude stroke 1, 2.
Complete Neurologic Examination
Include cranial nerve testing, cerebellar testing (finger-to-nose, heel-to-shin, rapid alternating movements), gait assessment, and observation for spontaneous nystagmus 3, 2
Orthostatic Blood Pressure
Measure blood pressure supine and after 1-3 minutes of standing to assess for postural hypotension 4, 5
Imaging Decisions
When NOT to Image
No imaging is indicated for 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 (when performed by trained examiner)
- Nonspecific dizziness without vertigo, ataxia, or neurologic deficits
When Imaging IS Required
MRI brain without contrast (with diffusion-weighted imaging) is indicated for 1, 2:
- Abnormal neurologic examination
- HINTS examination suggesting central cause
- High vascular risk patients with acute vestibular syndrome (even with normal neurologic exam)
- Unilateral or pulsatile tinnitus
- Asymmetric hearing loss
- Progressive neurologic symptoms
- Sudden unilateral hearing loss
- New severe headache accompanying dizziness
- Inability to stand or walk
- Downbeating nystagmus or other central nystagmus patterns
Critical Point: CT head has extremely low diagnostic yield (<1%) for isolated dizziness and misses most posterior circulation infarcts with only 20-40% sensitivity. MRI with diffusion-weighted imaging is far superior with 4% diagnostic yield 1, 3.
MRI head and internal auditory canal WITH and WITHOUT contrast is indicated for chronic recurrent vertigo with unilateral hearing loss or tinnitus to exclude vestibular schwannoma 1
Laboratory Testing
Laboratory testing has very low yield in patients with dizziness who have returned to baseline neurologic status 1.
Check fingerstick glucose immediately, as hypoglycemia is the most frequently identified unexpected abnormality 1. Consider basic metabolic panel only if history or examination suggests specific abnormalities. Avoid routine comprehensive laboratory panels as they rarely change management 1.
Treatment Based on Diagnosis
BPPV
Canalith repositioning procedures (Epley maneuver) are first-line treatment with 80% success after 1-3 treatments and 90-98% success with repeat maneuvers 1, 2. No imaging or medication is needed for typical cases 1. Educate patients about 10-18% recurrence rate at 1 year, up to 36% long-term 2.
Vestibular Neuritis
Initiate vestibular rehabilitation therapy as soon as possible 3. Vestibular suppressant medications (meclizine 25-100 mg daily in divided doses) may provide symptomatic relief 6, 7, though they can affect the central nervous system's ability to compensate for dizziness 5.
Ménière's Disease
Salt restriction and diuretics are first-line treatment 2, 7. Consider intratympanic dexamethasone or gentamicin for refractory cases 1, 4.
Vestibular Migraine
Migraine prophylaxis and lifestyle modifications are essential 1, 2. This diagnosis requires episodic vestibular symptoms, migraine by International Headache Society criteria, and at least two migraine symptoms during at least two vertiginous episodes 1.
Vestibular Rehabilitation Therapy
This is the primary intervention for persistent dizziness that has failed initial treatment, significantly improving gait stability compared to medication alone 1. It is particularly beneficial for elderly patients, those with CNS disorders, or heightened fall risk 1.
Common Diagnostic Pitfalls to Avoid
- Relying on symptom quality ("spinning" vs "lightheadedness") instead of focusing on timing and triggers 1, 2
- Assuming normal neurologic exam excludes stroke—75-80% of posterior circulation strokes have no focal deficits 1, 3
- Ordering imaging for straightforward BPPV, which delays treatment unnecessarily 3
- Skipping the Dix-Hallpike maneuver, the gold standard diagnostic test 3
- Using CT instead of MRI when stroke is suspected—CT misses most posterior circulation infarcts 1, 3
- Overlooking vestibular migraine, which is extremely common but under-recognized, particularly in young patients 3
- Failing to distinguish fluctuating hearing loss (Ménière's) from stable/absent hearing loss (vestibular migraine) 1, 3
- Not assessing fall risk in elderly patients with vestibular disorders 2
- Overlooking medication side effects as a common and reversible cause 1
Age-Specific Considerations
Elderly Patients
BPPV is present in 9% of elderly patients referred for geriatric evaluation, with three-fourths having fallen within the prior 3 months 1. Among community-dwelling adults aged >65 years, one in three falls annually, with dizziness being the primary etiology 13% of the time 1. Age-related physiological changes increase vulnerability, including reduced thirst, impaired sodium/water preservation, diminished baroreceptor response, and reduced heart rate response to orthostatic stress 1.
Young Adults
Vestibular migraine is extremely common and often under-recognized in this population 3. Always ask about current or past migraine history, family history of migraine, motion intolerance as a trigger, and photophobia, phonophobia, or visual aura during vertigo episodes 3.