How should dizziness be managed in patients?

Management of Dizziness

Dizziness management depends on categorizing the presentation by timing and triggers—not the patient's vague description—then applying specific bedside tests and targeted treatments, with imaging reserved only for red flag features. 1

Initial Clinical Approach: Categorize by Timing and Triggers

The first critical step is classifying dizziness into one of four vestibular syndromes based on duration and precipitating factors 1, 2:

• Brief episodic vertigo (seconds to minutes): Triggered by head position changes, strongly suggests Benign Paroxysmal Positional Vertigo (BPPV) 1
• Acute persistent vertigo (days to weeks): Constant symptoms suggest vestibular neuritis or posterior circulation stroke 1
• Spontaneous episodic vertigo (minutes to hours): Recurrent episodes without triggers suggest Ménière's disease or vestibular migraine 1
• Chronic vestibular syndrome (weeks to months): Persistent symptoms suggest medication side effects, anxiety disorders, or posttraumatic vertigo 1

Critical pitfall: Do not rely on whether patients describe "spinning" versus "lightheadedness"—these subjective descriptions are unreliable and should be ignored in favor of objective timing patterns 1, 3

Essential History Elements

Focus your questioning on these specific diagnostic details 1, 2:

• Duration of episodes: Seconds (BPPV), minutes to hours (vestibular migraine or Ménière's), days to weeks (vestibular neuritis or stroke) 1
• Positional triggers: Head movements triggering symptoms strongly suggest BPPV 1
• Associated auditory symptoms: Hearing loss, tinnitus, and aural fullness point to Ménière's disease 1
• Migraine features: Headache, photophobia, and phonophobia suggest vestibular migraine, which accounts for 14% of all vertigo cases but is frequently under-recognized 1
• Vascular risk factors: Age >50, hypertension, diabetes, atrial fibrillation, or prior stroke increase stroke risk 1
• Medication review: Antihypertensives, sedatives, anticonvulsants, and psychotropic drugs are leading causes of chronic dizziness 1

Physical Examination: Specific Bedside Tests

For Brief Episodic Vertigo (Suspected BPPV)

Perform the Dix-Hallpike maneuver as the gold standard diagnostic test 1, 2:

• Positive findings: 5-20 second latency before symptoms begin, torsional upbeating nystagmus toward the affected ear, symptoms and nystagmus that increase then resolve within 60 seconds 1
• If positive with typical features: No imaging or vestibular testing is needed—proceed directly to treatment 1, 3

For Acute Persistent Vertigo (Days to Weeks)

Perform the HINTS examination (Head Impulse, Nystagmus, Test of Skew) 1, 3:

• When performed by trained practitioners: 100% sensitivity for detecting posterior circulation stroke versus 46% sensitivity for early MRI 1
• Central features requiring urgent imaging: Normal head impulse test, direction-changing or vertical nystagmus, present skew deviation 1, 3
• Peripheral features (vestibular neuritis): Abnormal head impulse test, unidirectional horizontal nystagmus, absent skew deviation 1

Critical warning: 75-80% of patients with posterior circulation stroke have NO focal neurologic deficits on standard examination, making the HINTS examination essential 3

Additional Examination Components

• Observe for spontaneous nystagmus in all patients 2
• Complete neurologic examination to identify focal deficits suggesting central pathology 2
• Orthostatic vital signs if presyncope is suspected 4, 5

Red Flags Requiring Urgent Neuroimaging

These features mandate immediate MRI brain without contrast and neurologic consultation 1, 3:

• Focal neurological deficits: Diplopia, dysarthria, facial numbness, limb weakness, or sensory changes 3
• Sudden unilateral hearing loss with vertigo 3
• Inability to stand or walk independently 3
• New severe headache accompanying dizziness 1, 3
• Downbeating or other central nystagmus patterns 1, 3
• Abnormal HINTS examination suggesting central cause 1, 3
• Unilateral or pulsatile tinnitus (concern for cerebellopontine angle tumor or vascular malformation) 3
• Failure to respond to appropriate vestibular treatments 3

Imaging Decisions: When to Image and What to Order

Do NOT Image

• Brief episodic vertigo with typical BPPV features and positive Dix-Hallpike test 1, 3
• 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

Rationale: CT head has <1% diagnostic yield for isolated dizziness, and routine imaging yields mostly incidental findings 1, 3

MRI Brain Without Contrast IS Indicated

• High vascular risk patients with acute vestibular syndrome, even with normal neurologic examination (11-25% have posterior circulation stroke) 1, 2
• Abnormal neurologic examination 1, 2
• HINTS examination suggesting central cause 1, 2
• Progressive neurologic symptoms suggesting mass lesion 1

Critical point: MRI with diffusion-weighted imaging has 4% diagnostic yield versus <1% for CT, and CT misses most posterior circulation infarcts 1, 3

MRI Head and Internal Auditory Canal WITH and WITHOUT Contrast

• Chronic recurrent vertigo with unilateral hearing loss or tinnitus to exclude vestibular schwannoma 1
• Suspected Ménière's disease requiring definitive diagnosis 1

Treatment Based on Diagnosis

BPPV (Most Common Peripheral Cause)

Perform canalith repositioning procedures (Epley maneuver) immediately 1, 2:

• Success rates: 80% after 1-3 treatments, 90-98% with repeat maneuvers 1, 2
• No medications are needed for typical BPPV 1
• Counsel patients: 10-18% recurrence risk at one year, up to 36% long-term 2
• Fall prevention counseling: BPPV is present in 9% of elderly patients referred for geriatric evaluation, with three-fourths having fallen within the prior 3 months 1

Vestibular Neuritis (Acute Persistent Peripheral Vertigo)

• Vestibular rehabilitation therapy is the primary intervention for persistent dizziness that has failed initial treatment 1
• Significantly improves gait stability compared to medication alone, particularly beneficial for elderly patients or those with heightened fall risk 1
• Steroids may be considered in the acute phase 5

Ménière's Disease

• Salt restriction and diuretics as first-line management 1
• Intratympanic treatments (dexamethasone or gentamicin) for refractory cases 1, 5
• Obtain audiogram to document low-to-mid frequency sensorineural hearing loss 1
• Key distinguishing feature: Fluctuating hearing loss (versus stable/absent hearing loss in vestibular migraine) 1

Vestibular Migraine

• Migraine prophylaxis and lifestyle modifications 1, 2
• Diagnostic criteria: Episodic vestibular symptoms, migraine by International Headache Society criteria, and at least two migraine symptoms during at least two vertiginous episodes 1
• Often coexists with Ménière's: 35% of Ménière's patients also meet criteria for vestibular migraine 1

Orthostatic Hypotension Causing Presyncope

• Medication review and adjustment is essential 1, 5
• Midodrine can be considered for symptomatic orthostatic hypotension: raises standing systolic blood pressure by approximately 15-30 mmHg at 1 hour after a 10 mg dose, with effects persisting for 2-3 hours 6
• Alpha agonists, mineralocorticoids, or lifestyle changes for persistent cases 5

Chronic Dizziness Without Clear Peripheral Cause

• Medication review is crucial: Leading reversible cause of chronic vestibular syndrome 1
• Screen for psychiatric symptoms: Anxiety, panic disorder, and depression are common causes 1
• Vestibular rehabilitation therapy for persistent symptoms 1

Special Considerations for Elderly Patients

Elderly patients with dizziness require heightened vigilance 1:

• Dizziness increases fall risk 12-fold in elderly patients 1
• Age-related physiological changes increase vulnerability: reduced thirst, impaired sodium/water preservation, diminished baroreceptor response, reduced heart rate response to orthostatic stress 1
• Among community-dwelling adults aged >65 years: One in three falls annually, with estimated costs exceeding $20 billion annually in the United States 1
• BPPV treatment success: Same high success rates with Epley maneuver, but counsel about fall risk and consider home supervision if frail 1

Laboratory Testing: Very Limited Role

• Check fingerstick glucose immediately: Hypoglycemia is the most frequently identified unexpected abnormality 1
• Basic metabolic panel only if history or examination suggests specific abnormalities 1
• Do NOT order routine comprehensive laboratory panels: They rarely change management 1

Quality of Life Impact and Prognosis

Understanding the burden of vestibular disorders helps frame management urgency 7:

• During acute Ménière's disease attacks: Quality of well-being ratings fall between noninstitutionalized Alzheimer's patients and end-stage cancer or AIDS patients 7
• Ménière's disease patients: More than twice as likely to have experienced 2 falls in a year (13.7% vs 6.6%) 7
• Work impact: 86% report job performance suffered, 70% had to modify jobs, 35% changed jobs 7

Common Pitfalls to Avoid

• Do not assume normal neurologic exam excludes stroke: 75-80% of posterior circulation stroke patients have no focal deficits 3
• Do not use CT instead of MRI when stroke is suspected: CT misses many posterior circulation infarcts 3
• Do not order routine imaging for isolated dizziness with typical peripheral features: Diagnostic yield is extremely low 3
• Do not skip bedside testing: Dix-Hallpike and HINTS examinations provide more diagnostic value than imaging in most cases 3
• Do not overlook medication side effects: One of the most common and reversible causes 1
• Do not miss vestibular migraine: Extremely common (14% of all vertigo) but frequently under-recognized, particularly in young patients 1