What is the approach to diagnosing and treating a patient presenting with vertigo?

Approach to Diagnosing and Treating Vertigo

Classify vertigo by timing and triggers—not the patient's vague description of "dizziness"—then perform targeted physical examination maneuvers to distinguish peripheral from central causes, reserving imaging only for red flags. 1

Initial Classification by Temporal Pattern

The American Academy of Otolaryngology-Head and Neck Surgery recommends categorizing vertigo into four distinct syndromes based on duration and triggers, as this approach is far more diagnostically valuable than subjective symptom descriptions 1:

• Brief episodic vertigo (seconds to <1 minute): Triggered by specific head position changes, suggests BPPV, superior canal dehiscence, or perilymphatic fistula 1, 2
• Spontaneous episodic vertigo (minutes to hours): Unprovoked episodes suggest vestibular migraine (14% of all vertigo cases), Ménière's disease, or vertebrobasilar insufficiency 1, 2
• Acute vestibular syndrome (days to weeks): Continuous severe vertigo suggests vestibular neuritis, labyrinthitis, or posterior circulation stroke 1, 2
• Chronic vestibular syndrome (weeks to months): Persistent symptoms suggest anxiety/panic disorder, medication side effects, or posterior fossa mass 1, 2

Critical Physical Examination Maneuvers

For Brief Episodic Vertigo (Suspected BPPV)

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

• Positive findings (peripheral/BPPV): 5-20 second latency before onset, torsional upbeating nystagmus toward the affected ear, crescendo-decrescendo pattern that resolves within 60 seconds, fatigues with repeat testing 1, 2
• Red flag findings (central pathology): Immediate onset without latency, persistent nystagmus that doesn't fatigue, purely vertical nystagmus without torsional component, downbeating nystagmus 1, 3

If Dix-Hallpike is negative but history suggests BPPV, perform the Supine Roll Test to diagnose lateral canal BPPV (10-15% of BPPV cases) 2

For Acute Vestibular Syndrome

The HINTS examination (Head Impulse, Nystagmus, Test of Skew) has 100% sensitivity for detecting posterior circulation stroke when performed by trained practitioners—superior to early MRI (46% sensitivity) 1, 2:

• Peripheral features (reassuring): Abnormal head impulse test (corrective saccade), unidirectional horizontal nystagmus, absent skew deviation 1
• Central features (dangerous): Normal head impulse test, direction-changing or vertical nystagmus, present skew deviation 1, 2

Critical caveat: HINTS is less reliable when performed by non-experts, so if you lack training, proceed directly to imaging for high-risk patients 1

Distinguishing Peripheral from Central Vertigo

Nystagmus Characteristics

Peripheral vertigo nystagmus 3:

• Horizontal with rotatory component
• Unidirectional (doesn't change with gaze direction)
• Suppressed by visual fixation
• Fatigable with repeated testing
• Brief latency period before onset

Central vertigo nystagmus 3:

• Pure vertical without torsional component
• Direction-changing without head position changes
• NOT suppressed by visual fixation
• Persistent without modification on repeat testing
• Baseline nystagmus present without provocative maneuvers

Associated Symptoms

• Peripheral: Auditory symptoms (hearing loss, tinnitus, aural fullness), episodes triggered by specific head movements, no neurologic symptoms beyond vertigo 2, 3
• Central: Dysarthria, dysmetria, dysphagia, sensory/motor deficits, diplopia, Horner's syndrome, severe postural instability with falling 2, 3

Red Flags Requiring Urgent MRI Brain Without Contrast

Any of the following mandate immediate neuroimaging and neurologic consultation 1, 2:

• Focal neurological deficits on examination
• Sudden unilateral hearing loss
• Inability to stand or walk (severe postural instability)
• Downbeating or other central nystagmus patterns
• New severe headache accompanying dizziness
• HINTS examination suggesting central cause
• Failure to respond to appropriate peripheral vertigo treatments
• High vascular risk (age >50, hypertension, diabetes, atrial fibrillation, prior stroke) with acute vestibular syndrome—even with normal neurologic exam, as 11-25% have posterior circulation stroke 1

Critical pitfall: 75-80% of patients with posterior circulation stroke causing acute vestibular syndrome have NO focal neurologic deficits initially, so a normal neurologic exam does NOT exclude stroke 1, 2

Imaging Strategy

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 consistent with peripheral vertigo (by trained examiner)
• Nonspecific dizziness without vertigo, ataxia, or neurologic deficits

When to Image

MRI brain without contrast is the preferred modality (NOT CT, which has <1% diagnostic yield vs 4% for MRI and misses most posterior circulation infarcts) 1, 2:

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

MRI head and internal auditory canal with and without contrast for chronic recurrent vertigo with unilateral hearing loss or tinnitus to exclude vestibular schwannoma 1

CT head without contrast may be appropriate as initial imaging in acute settings when stroke is suspected, but has severe limitations and should be followed by MRI 1

Treatment by Diagnosis

BPPV (Most Common Cause—42% of Peripheral Vertigo Cases)

Perform canalith repositioning procedures (Epley maneuver) immediately upon diagnosis as first-line treatment 1, 2, 3:

• 80% success rate after 1-3 treatments 1
• 90-98% success with repeat maneuvers if initial treatment fails 1
• Do NOT prescribe vestibular suppressants for BPPV—they prevent central compensation and are unnecessary 1, 3
• No imaging or laboratory testing needed for typical BPPV with positive Dix-Hallpike and no red flags 1, 2
• Reassess within 1 month to document resolution or persistence 1

Vestibular Neuritis/Labyrinthitis (41% of Peripheral Vertigo Cases)

Initial stabilization with vestibular suppressant medication, followed by vestibular rehabilitation exercises 4:

• Meclizine 25-100 mg daily orally in divided doses is FDA-approved for vertigo associated with vestibular system diseases 5
• Important caveat: Meclizine causes drowsiness; warn patients against driving or operating machinery, avoid alcohol, use with caution in asthma/glaucoma/prostate enlargement 5
• Vestibular rehabilitation therapy is the primary intervention for persistent dizziness that fails initial treatment, significantly improving gait stability compared to medication alone 1

Ménière's Disease (10-43% of Vertigo Cases Depending on Setting)

Characterized by episodic vertigo lasting 20 minutes to 12 hours with fluctuating sensorineural hearing loss, tinnitus, and aural fullness 1, 2:

• Dietary sodium restriction and diuretics 1, 4
• Obtain audiogram to document low-to-mid frequency sensorineural hearing loss 1
• Key distinguishing feature from vestibular migraine: Fluctuating hearing loss that worsens over time (vs stable/absent hearing loss in vestibular migraine) 1, 3

Vestibular Migraine (14% of All Vertigo Cases—Extremely Under-Recognized)

Diagnostic criteria: Episodic vestibular symptoms, migraine by International Headache Society criteria, and at least two migraine symptoms (headache, photophobia, phonophobia, visual aura) during at least two vertiginous episodes 1, 3:

• Migraine prophylaxis and lifestyle modifications 1, 4
• Episodes can be short (<15 minutes) or prolonged (>24 hours) 3
• Motion intolerance and light sensitivity help differentiate from Ménière's 1
• Common pitfall: Vestibular migraine is extremely common in young women but often overlooked 1, 3

Medication-Induced Vertigo

Review antihypertensives, sedatives, anticonvulsants, and psychotropic drugs—medication side effects are a leading reversible cause of chronic vestibular syndrome 1, 3

Laboratory Testing

Laboratory testing has very low yield in vertigo and is NOT routinely recommended 2:

• Check fingerstick glucose immediately—hypoglycemia is the most frequently identified unexpected abnormality 1
• Consider basic metabolic panel only if history/examination suggests specific abnormalities 1
• Do NOT order routine comprehensive laboratory panels—they rarely change management 1
• Audiometry is appropriate when auditory symptoms suggest Ménière's disease or other inner ear pathology 2
• Consider autoimmune panels only for progressive fluctuating bilateral hearing loss that may be steroid-responsive 2
• Order serologic testing for Lyme disease or otosyphilis only when clinical presentation suggests infectious causes 2

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—three-fourths had fallen within the prior 3 months 1
• Document number of falls in past year, circumstances, and injuries sustained 1
• Age-related physiological changes increase vulnerability: reduced thirst, impaired sodium/water preservation, diminished baroreceptor response, reduced heart rate response to orthostatic stress 1
• Vestibular rehabilitation therapy is particularly beneficial for elderly patients or those with heightened fall risk 1

Common Diagnostic Pitfalls to Avoid

• Relying on patient's description of "spinning" vs "lightheadedness" instead of focusing on timing and triggers 1
• Assuming normal neurologic exam excludes stroke—75-80% of posterior circulation strokes have no focal deficits initially 1, 2
• Using CT instead of MRI when stroke is suspected—CT misses most posterior circulation infarcts 1
• Routine imaging for isolated dizziness—has very low yield (<1% for CT) and most findings are incidental 1
• Overlooking vestibular migraine—extremely common but under-recognized, particularly in young patients 1, 3
• Failing to distinguish fluctuating hearing loss (Ménière's) from stable/absent hearing loss (vestibular migraine) 1, 3
• Prescribing vestibular suppressants for BPPV—they prevent central compensation 1, 3
• Performing Dix-Hallpike when Romberg is positive—this indicates central pathology requiring imaging first 2