What is the approach to evaluating and managing a patient with dizziness, considering their demographic, medical history, and potential underlying causes such as inner ear problems, cardiovascular disease, or neurological disorders?

Approach to Dizziness

Begin by categorizing dizziness based on timing and triggers rather than the patient's subjective description, as this is the most diagnostically valuable approach to distinguish benign peripheral causes from dangerous central pathology like stroke. 1

Initial Classification by Timing

The first critical step is to determine which of four temporal patterns the patient's dizziness follows:

• Brief episodic vertigo (seconds to minutes): Triggered by head position changes, strongly suggests benign paroxysmal positional vertigo (BPPV), which accounts for 42% of peripheral vertigo cases 1, 2
• Acute persistent vertigo (days to weeks): Constant symptoms with nausea/vomiting suggest vestibular neuritis, labyrinthitis, or posterior circulation stroke—approximately 25% of acute vestibular syndrome cases have cerebrovascular disease, rising to 75% in high vascular risk cohorts 1, 3
• Spontaneous episodic vertigo (minutes to hours): Recurrent episodes without positional trigger suggest vestibular migraine (14% of all vertigo cases) or Ménière's disease 1, 3
• Chronic vestibular syndrome (weeks to months): Persistent symptoms suggest medication side effects, anxiety/panic disorder, posttraumatic vertigo, or posterior fossa mass lesions 1

Critical History Elements

Distinguish True Vertigo from Vague Dizziness

True vertigo is defined as a false sensation of self-motion or spinning of the visual surroundings, which is specific for inner ear dysfunction. 4 Many patients use "dizziness" to describe lightheadedness or presyncope, which are not consistent with vestibular disorders and may indicate cardiovascular causes. 4

Essential Associated Symptoms

• Hearing loss, tinnitus, and aural fullness: Point to Ménière's disease, with fluctuating hearing loss being the key distinguishing feature from vestibular migraine 1, 3
• Headache, photophobia, and phonophobia: Strongly suggest vestibular migraine, which is extremely common but under-recognized, particularly in young patients 1, 3
• Focal neurological symptoms (dysarthria, diplopia, numbness, weakness): Red flags for central pathology requiring urgent imaging 1, 3

Medication Review

Medication side effects are a leading reversible cause of chronic dizziness, particularly antihypertensives, sedatives, anticonvulsants, and psychotropic drugs. 1 This should be addressed early as it represents a common and treatable etiology.

Vascular Risk Factors

Age >50, hypertension, atrial fibrillation, diabetes, and prior stroke significantly increase stroke risk in patients presenting with acute vestibular syndrome. 1 High vascular risk patients with acute vestibular syndrome require MRI even with normal neurologic examination, as 11-25% may have posterior circulation stroke. 1

Physical Examination

For Brief Episodic Vertigo

Perform the Dix-Hallpike maneuver as the gold standard diagnostic test for BPPV 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 1
• Torsional, upbeating nystagmus toward the affected ear 1
• Vertigo and nystagmus that increase then resolve within 60 seconds 1

For Acute Persistent Vertigo

The HINTS examination (Head-Impulse, Nystagmus, Test of Skew) has 100% sensitivity for detecting stroke when performed by trained practitioners, compared to only 46% sensitivity for early MRI. 1 However, when performed by non-experts, results are less reliable. 1

Components suggesting peripheral vertigo:

• Abnormal head impulse test (corrective saccade)
• Unidirectional horizontal nystagmus
• Absent skew deviation

Components suggesting central vertigo (stroke):

• Normal head impulse test
• Direction-changing or vertical nystagmus
• Present skew deviation

Neurologic Examination

Perform thorough cranial nerve testing, cerebellar testing (finger-to-nose, heel-to-shin, rapid alternating movements), gait assessment, and observation for spontaneous nystagmus. 3 A critical pitfall is assuming a normal neurologic exam excludes stroke—75-80% of patients with posterior circulation stroke have no focal neurologic deficits. 1, 3

Orthostatic Blood Pressure

Check orthostatic vital signs if presyncope is suspected, as postural hypotension is a common cause of dizziness, particularly in elderly patients. 1, 5

Red Flags Requiring Urgent Neuroimaging

The following mandate immediate MRI brain without contrast and neurologic consultation:

• Focal neurological deficits on examination 1, 3
• Sudden unilateral hearing loss 1, 3
• Inability to stand or walk 1, 3
• Downbeating or other central nystagmus patterns 1, 3
• New severe headache accompanying dizziness 1, 3
• Progressive neurologic symptoms 1
• HINTS examination suggesting central cause 1
• Failure to respond to appropriate vestibular treatments 1

Imaging Decisions

When Imaging is NOT Indicated

• Brief episodic vertigo with typical BPPV features and positive Dix-Hallpike test 1
• Acute persistent vertigo with normal neurologic exam and HINTS examination consistent with peripheral vertigo by a trained examiner 1
• Nonspecific dizziness without vertigo, ataxia, or neurologic deficits 1

Routine imaging for isolated dizziness has extremely low yield—CT detects causative pathology in less than 1% of cases. 1

When MRI is Indicated

MRI brain without contrast is the preferred imaging modality for:

• High vascular risk patients with acute vestibular syndrome, even with normal neurologic examination 1
• Abnormal neurologic examination 1
• HINTS examination suggesting central cause 1
• Unilateral or pulsatile tinnitus 1
• Asymmetric hearing loss 1
• Progressive neurologic symptoms suggesting mass lesion 1

MRI with diffusion-weighted imaging is far superior to CT for diagnosing posterior circulation infarcts, with 4% diagnostic yield versus <1% for CT. 1 CT should not be used instead of MRI when stroke is suspected, as it misses most posterior circulation infarcts with only 20-40% sensitivity. 1, 3

Special Imaging Considerations

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. 1 Avoid ordering routine comprehensive laboratory panels, as they rarely change management. 1

Treatment Based on Diagnosis

Benign Paroxysmal Positional Vertigo

Canalith repositioning procedures (Epley maneuver) are first-line treatment for BPPV, with 80% success after 1-3 treatments and 90-98% success with repeat maneuvers. 1, 3 No imaging or medication is needed for typical cases. 1 Patients should be counseled about recurrence risk, fall risk, and the importance of returning promptly if symptoms recur for repeat repositioning procedures. 1

Vestibular Neuritis

Vestibular rehabilitation therapy should be initiated as soon as possible, as it significantly improves gait stability compared to medication alone and is particularly beneficial for elderly patients or those with heightened fall risk. 1, 3

Vestibular Migraine

Migraine prophylaxis and lifestyle modifications are essential, with motion intolerance and light sensitivities helping to differentiate from Ménière's disease. 1, 3 Vestibular migraine is extremely common (14% of all vertigo cases) but under-recognized, particularly in young patients. 1, 3

Ménière's Disease

Initial management includes salt restriction and diuretics, with intratympanic treatments reserved for refractory cases. 1 Obtain audiograms to document low-to-mid frequency sensorineural hearing loss. 1 Note that 35% of Ménière's patients also meet criteria for vestibular migraine. 1

Medication-Induced Dizziness

Review and adjust medications, as this is one of the most common and reversible causes of chronic dizziness. 1

Common Diagnostic Pitfalls to Avoid

• Relying on patient's description of "spinning" versus "lightheadedness" instead of focusing on timing and triggers 1, 3
• Assuming normal neurologic exam excludes stroke, as 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
• Overlooking vestibular migraine, which is extremely common but under-recognized 1, 3
• Failing to distinguish fluctuating hearing loss (Ménière's) from stable/absent hearing loss (vestibular migraine) 1, 3
• Using CT instead of MRI when stroke is suspected, as CT misses many posterior circulation infarcts 1, 3

Special Considerations for Elderly Patients

Dizziness increases fall risk 12-fold in elderly patients. 1 BPPV is present in 9% of elderly patients referred for geriatric evaluation, with three-fourths having fallen within the prior 3 months. 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 Document the number of falls in the past year, circumstances, and injuries sustained. 1