What is the initial workup for a patient presenting with dizziness, considering age, medical history, and nature of dizziness (e.g., vertigo, lightheadedness, or unsteadiness)?

Initial Workup for Dizziness

The initial workup for dizziness should focus on precise timing and triggers rather than the patient's vague description of symptoms, followed by targeted physical examination including the Dix-Hallpike maneuver and HINTS examination when appropriate, with imaging reserved only for red flag features. 1

Step 1: Categorize by Timing and Triggers

The American College of Radiology emphasizes that focusing on specific timing patterns is far more diagnostically valuable than asking patients to describe their dizziness as "spinning" versus "lightheadedness." 1 Classify into one of four temporal patterns:

Brief Episodic (Seconds to <1 Minute)

• Triggered by head position changes → Strongly suggests BPPV 1
• Most common cause of peripheral vertigo (42% of cases) 1
• Proceed directly to Dix-Hallpike maneuver 1

Acute Persistent (Days to Weeks)

• Constant symptoms with nausea/vomiting → Consider vestibular neuritis, labyrinthitis, or posterior circulation stroke 1
• Approximately 25% of acute vestibular syndrome cases have cerebrovascular disease, rising to 75% in high vascular risk cohorts 1
• Requires HINTS examination if trained examiner available 1

Spontaneous Episodic (Minutes to Hours)

• No positional trigger, recurrent episodes → Consider vestibular migraine or Ménière's disease 1
• Vestibular migraine accounts for 14% of all vertigo cases but is extremely under-recognized 1
• Ménière's disease characterized by fluctuating hearing loss, tinnitus, and aural fullness 1

Chronic (Weeks to Months)

• Persistent symptoms → Consider medication side effects (leading reversible cause), anxiety/panic disorder, or posttraumatic vertigo 1
• Medication review is essential, particularly antihypertensives, sedatives, anticonvulsants, and psychotropic drugs 1

Step 2: Identify Critical Associated Symptoms

Red Flags Requiring Urgent Imaging

• Focal neurological deficits (dysarthria, diplopia, numbness, weakness) 1
• Sudden unilateral hearing loss 1
• Inability to stand or walk 1
• New severe headache accompanying dizziness 1
• Downbeating or direction-changing nystagmus 1

Diagnostic Clues

• Headache, photophobia, phonophobia → Vestibular migraine 1
• Hearing loss, tinnitus, aural fullness → Ménière's disease (fluctuating hearing loss is key distinguishing feature) 1
• Unilateral or pulsatile tinnitus → Requires MRI to exclude vestibular schwannoma 1

Step 3: Targeted Physical Examination

Essential Maneuvers

Dix-Hallpike Maneuver (Gold Standard for BPPV):

• Perform bilaterally in every patient with brief episodic positional dizziness 1
• Positive findings: 5-20 second latency, torsional upbeating nystagmus toward affected ear, symptoms resolve within 60 seconds 1
• Critical pitfall: Skipping this test delays diagnosis and treatment unnecessarily 2

HINTS Examination (For Acute Persistent Vertigo):

• Has 100% sensitivity for detecting stroke when performed by trained practitioners (vs. 46% for early MRI) 1
• Components suggesting central (stroke) cause: normal head impulse test, direction-changing or vertical nystagmus, present skew deviation 1
• Major caveat: Results are unreliable when performed by non-experts 1

Orthostatic Vital Signs:

• Check in all patients, particularly elderly 3
• Measure immediately, at 1 minute, and at 3 minutes (delayed orthostatic hypotension may not be captured by standard timing) 1

Neurologic Examination:

• Cranial nerve testing, cerebellar testing, gait assessment 1
• Critical pitfall: 75-80% of patients with posterior circulation stroke have NO focal neurologic deficits 1

Step 4: Age-Specific Considerations

Elderly Patients (>65 Years)

• BPPV present in 9% of elderly patients at geriatric evaluation; three-fourths had fallen within prior 3 months 1
• Dizziness increases fall risk 12-fold 3
• Polypharmacy is major contributor (diuretics, β-blockers, calcium antagonists, ACE inhibitors, antipsychotics, tricyclics) 3
• Age-related changes: reduced baroreceptor response, diminished heart rate response to orthostatic stress, autonomic dysfunction 1

Young Adults

• Vestibular migraine is extremely common but under-recognized 2
• Ask about current/past migraine history, family history of migraine, motion intolerance 2
• 34% of BPPV patients have migraine history 3

Step 5: Imaging Decisions

DO NOT Image (No Indication):

• Brief episodic vertigo with positive Dix-Hallpike test and no red flags 1
• Acute persistent vertigo with normal neurologic exam AND peripheral HINTS by trained examiner 1
• Nonspecific dizziness without vertigo, ataxia, or neurologic deficits 1
• Routine imaging has <1% diagnostic yield in isolated dizziness 1

MRI Brain Without Contrast (Preferred Imaging):

• Abnormal neurologic examination 1
• HINTS examination suggesting central cause 1
• High vascular risk patients (age >50, hypertension, diabetes, atrial fibrillation, prior stroke) with acute vestibular syndrome, even with normal neurologic exam (11-25% have posterior circulation stroke) 1
• Unilateral or pulsatile tinnitus 1
• Asymmetric hearing loss 1
• Progressive neurologic symptoms 1

MRI Internal Auditory Canal With and Without Contrast:

• Chronic recurrent vertigo with unilateral hearing loss or tinnitus to exclude vestibular schwannoma 1

CT Head (Limited Role):

• May be appropriate in acute settings before MRI when stroke suspected 1
• Major limitation: Only 20-40% sensitivity for posterior circulation infarcts, misses most causative pathology 1
• Never use CT instead of MRI when stroke is suspected 1

Step 6: Laboratory Testing

Minimal Role in Most Cases:

• Check fingerstick glucose immediately (hypoglycemia is most frequently identified unexpected abnormality) 1
• Basic metabolic panel only if history/examination suggests specific abnormalities 1
• Avoid routine comprehensive laboratory panels (rarely change management) 1

Audiologic Testing:

• Obtain comprehensive audiologic examination for unilateral tinnitus, persistent symptoms, or associated hearing difficulties 1
• Documents low-to-mid frequency sensorineural hearing loss in Ménière's disease 1

Step 7: Immediate Treatment Based on Diagnosis

BPPV (Most Common):

• Canalith repositioning procedure (Epley maneuver) is first-line treatment 1
• 80% success after 1-3 treatments, 90-98% with repeat maneuvers 1
• No imaging or medication needed for typical cases 1

Vestibular Neuritis:

• Vestibular rehabilitation therapy initiated as soon as possible 2
• Vestibular suppressants for acute symptom relief 4

Ménière's Disease:

• Salt restriction and diuretics 1
• Intratympanic treatments for refractory cases 5

Vestibular Migraine:

• Migraine prophylaxis and lifestyle modifications 1

Common Pitfalls to Avoid

1. Relying on patient's description of "spinning" vs "lightheadedness" instead of timing/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 (delays treatment unnecessarily) 2
4. Using CT instead of MRI when stroke suspected (CT misses most posterior circulation infarcts) 1
5. Overlooking vestibular migraine in young patients (extremely common but under-recognized) 2
6. Failing to review medications in elderly patients (leading reversible cause of chronic dizziness) 1
7. Skipping Dix-Hallpike maneuver (gold standard diagnostic test) 2