What is the approach to evaluating a patient presenting with dizziness, considering their past medical history, current medications, and potential underlying conditions such as hypertension (High Blood Pressure), diabetes, neurological disorders, or cardiovascular issues?

Systematic Approach to Dizziness Workup

Categorize dizziness by timing and triggers rather than relying on the patient's subjective description of symptoms, as this approach is far more diagnostically valuable and distinguishes benign peripheral causes from dangerous central pathology like stroke. 1

Initial History: Focus on Timing and Triggers

The quality of dizziness ("spinning" vs "lightheadedness") is unreliable and should not guide your evaluation 1. Instead, systematically determine:

Timing Categories

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

Critical Associated Symptoms

Red flags requiring urgent neuroimaging: 1, 3

• Focal neurological deficits (dysarthria, diplopia, numbness, weakness)
• Sudden unilateral hearing loss
• Inability to stand or walk
• New severe headache accompanying dizziness
• Downbeating or other central nystagmus patterns
• Progressive neurologic symptoms

Peripheral vestibular clues: 1, 3

• Hearing loss, tinnitus, aural fullness → Ménière's disease (key: fluctuating hearing loss)
• Headache, photophobia, phonophobia → vestibular migraine

Essential Historical Details

• Duration of each episode: Seconds (BPPV), minutes to hours (vestibular migraine or Ménière's), days to weeks (vestibular neuritis or stroke) 1
• Onset: Spontaneous vs provoked by head position 4
• Vascular risk factors: Age >50, hypertension, diabetes, atrial fibrillation, prior stroke (11-25% of high-risk patients with acute vestibular syndrome have posterior circulation stroke) 1
• Medication review: Antihypertensives (including metoprolol, which commonly causes dizziness and vertigo 5), sedatives, anticonvulsants, psychotropic drugs are leading reversible causes 1
• Migraine history: Current, past, or family history—vestibular migraine accounts for 14% of all vertigo cases but is extremely under-recognized, particularly in young patients 1, 3
• Falls: Document number in past year, circumstances, injuries—dizziness increases fall risk 12-fold in elderly 1

Physical Examination: Targeted Maneuvers

Mandatory Bedside Tests

Dix-Hallpike maneuver (for brief episodic dizziness): 1, 3, 2

• Gold standard for BPPV diagnosis
• Positive findings: 5-20 second latency, torsional upbeating nystagmus toward affected ear, symptoms resolve within 60 seconds
• Critical pitfall: Skipping this test delays diagnosis and treatment unnecessarily

HINTS examination (for acute persistent vertigo): 1, 3

• Head-Impulse, Nystagmus, Test of Skew
• 100% sensitivity for detecting stroke when performed by trained practitioners (vs 46% for early MRI)
• Warning: Less reliable when performed by non-experts
• Central features: Normal head impulse test, direction-changing nystagmus, positive skew deviation

Neurologic examination: 1, 3

• Cranial nerve testing
• Cerebellar testing (finger-to-nose, heel-to-shin, rapid alternating movements)
• Gait assessment
• Observation for spontaneous nystagmus (particularly central patterns)

Orthostatic vital signs: Check if presyncope suspected 6, 7

Critical Pitfall to Avoid

Assuming a normal neurologic exam excludes stroke is dangerous—75-80% of patients with acute vestibular syndrome from posterior circulation infarct have NO focal neurologic deficits. 1, 3

Diagnostic Testing: When and What to Order

Imaging Guidelines

NO imaging indicated for: 1

• Brief episodic vertigo with typical BPPV features and positive Dix-Hallpike test
• Acute persistent vertigo with normal neurologic exam AND HINTS consistent with peripheral vertigo by trained examiner
• Nonspecific dizziness without vertigo, ataxia, or neurologic deficits

MRI brain without contrast indicated for: 1

• 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
• Any red flag symptoms listed above

MRI head and internal auditory canal WITH and WITHOUT contrast: 1

• Chronic recurrent vertigo with unilateral hearing loss or tinnitus (to exclude vestibular schwannoma)
• Suspected Ménière's disease requiring definitive diagnosis

CT head has extremely low diagnostic yield (<1%) for isolated dizziness and misses most posterior circulation infarcts (sensitivity only 20-40%)—do NOT use CT instead of MRI when stroke is suspected. 1

Laboratory Testing

Routine labs have very low yield and should NOT be ordered routinely 1. Consider only:

• Fingerstick glucose immediately (hypoglycemia is most frequently identified unexpected abnormality) 1
• Basic metabolic panel only if history/exam suggests specific abnormalities 1
• Pregnancy test in reproductive-age females 2

Audiologic Testing

Comprehensive audiogram indicated for: 1

• Unilateral tinnitus
• Persistent symptoms
• Associated hearing difficulties
• Suspected Ménière's disease (documents low-to-mid frequency sensorineural hearing loss)

Treatment Based on Diagnosis

BPPV (Most Common Cause)

Canalith repositioning procedure (Epley maneuver) is first-line treatment with 80% success after 1-3 treatments and 90-98% success with repeat maneuvers. 1, 3

• No medications needed 1
• No imaging needed for typical cases 1
• Counsel about 10-18% recurrence rate at 1 year 2
• Reassess within one month 1

Vestibular Migraine

• Migraine prophylaxis and lifestyle modifications 1, 3
• Motion intolerance and light sensitivities help differentiate from Ménière's 4

Ménière's Disease

• Salt restriction and diuretics 1
• Intratympanic dexamethasone or gentamicin for refractory cases 8
• Key distinguishing feature: fluctuating hearing loss (vs stable/absent in vestibular migraine) 1

Vestibular Neuritis

• Vestibular rehabilitation therapy initiated as soon as possible 3
• Steroids may be beneficial 8
• Vestibular suppressants only for acute phase (avoid prolonged use as it delays central compensation) 6, 7

Persistent Dizziness After Initial Treatment

Vestibular rehabilitation therapy is the primary intervention, significantly improving gait stability compared to medication alone, particularly beneficial for elderly patients or those with heightened fall risk. 1

Common Diagnostic Pitfalls

1. Relying on patient's description of "spinning" vs "lightheadedness" instead of timing and triggers 1, 3
2. Ordering imaging for straightforward BPPV without concerning features—delays treatment unnecessarily 1, 3
3. Using CT instead of MRI when stroke suspected—CT misses most posterior circulation infarcts 1
4. Overlooking vestibular migraine—extremely common but under-recognized, especially in young patients 1, 3
5. Failing to review medications—one of most common and reversible causes of chronic dizziness 1
6. Assuming normal exam excludes stroke—most posterior circulation strokes lack focal deficits 1, 3
7. Ordering routine comprehensive lab panels—rarely change management 1