What are the first steps in managing a patient with dizziness?

Managing a Patient with Dizziness

The first critical step is to classify dizziness by timing and triggers—not by the patient's vague description—to distinguish benign peripheral causes from life-threatening central pathology like stroke. 1

Initial History: Focus on Timing and Triggers

The patient's subjective description of "spinning" versus "lightheadedness" is unreliable and should not guide your evaluation. 1 Instead, immediately determine:

Duration of Episodes

• Seconds only (<1 minute): Strongly suggests BPPV 1, 2
• Minutes to hours: Consider vestibular migraine or Ménière's disease 1, 2
• Days to weeks (constant): Suggests acute vestibular syndrome—requires differentiation between vestibular neuritis versus posterior circulation stroke 1, 3

Triggering Factors

• Head position changes: BPPV is the most common cause (42% of peripheral vertigo cases) 1
• Standing up: Consider orthostatic hypotension or medication effects 1
• Spontaneous (no trigger): Vestibular migraine, Ménière's disease, or vestibular neuritis 1

Associated Symptoms

• Hearing loss, tinnitus, aural fullness: Ménière's disease or labyrinthitis 1, 3
• Headache with photophobia/phonophobia: Vestibular migraine (accounts for 14% of all vertigo cases but is severely under-recognized) 1, 2
• New severe headache: Red flag mandating immediate imaging 1

Essential Physical Examination

For Brief Episodic Vertigo (Suspected BPPV)

Perform the Dix-Hallpike maneuver bilaterally—this is the gold standard diagnostic test. 4, 1 Look for:

• 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

If the Dix-Hallpike is negative but history suggests BPPV, perform the supine roll test to assess for lateral semicircular canal BPPV. 4

For Acute Persistent Vertigo (Days to Weeks)

Perform the HINTS examination (Head-Impulse, Nystagmus, Test of Skew) if you are trained in this technique—it has 100% sensitivity for detecting stroke versus 46% for early MRI. 1, 3

Critical warning: HINTS is unreliable when performed by non-experts. 1 If you lack expertise, proceed directly to neuroimaging for high-risk patients.

Central (stroke) features include:

• Normal head impulse test (abnormal suggests peripheral) 1
• Direction-changing or vertical nystagmus 1, 2
• Present skew deviation 1

Complete Neurologic Examination

Perform focused posterior circulation assessment including cranial nerves, cerebellar testing (finger-to-nose, heel-to-shin), gait assessment, and sensory/motor examination. 2

Critical pitfall: Up to 75-80% of patients with posterior circulation stroke have NO focal neurologic deficits. 1 A normal neurologic exam does NOT exclude stroke.

Red Flags Requiring Urgent Neuroimaging

Obtain MRI brain without contrast (NOT CT—CT misses most posterior circulation infarcts) immediately for: 1, 3

• Focal neurological deficits on examination 1
• Sudden unilateral hearing loss 1, 3
• Inability to stand or walk 1
• Downbeating nystagmus or other central nystagmus patterns 1, 2
• New severe headache accompanying dizziness 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, as 11-25% have posterior circulation stroke 1

When NOT to Order Imaging

Do not order imaging for: 1

• Brief episodic vertigo with positive Dix-Hallpike test and no additional concerning features 4, 1
• Acute persistent vertigo with normal neurologic exam and HINTS consistent with peripheral vertigo (by trained examiner) 1
• Nonspecific dizziness without vertigo, ataxia, or neurologic deficits 1

CT head has <1% diagnostic yield for isolated dizziness and should be avoided. 1 MRI with diffusion-weighted imaging is far superior (4% diagnostic yield). 1

Initial Treatment Based on Diagnosis

BPPV (Most Common Cause)

Immediately perform canalith repositioning procedure (Epley maneuver)—80% success after 1-3 treatments, 90-98% with repeat maneuvers. 1, 3 No medications or imaging needed for typical cases. 4

Strong recommendation against: Do not prescribe vestibular suppressants (antihistamines, benzodiazepines) for BPPV—they are ineffective and delay recovery. 4

Medication Review

Medication side effects are a leading reversible cause of chronic dizziness. 1 Review antihypertensives, sedatives, anticonvulsants, and psychotropic drugs. 1

Mandatory Follow-Up

Reassess within 1 month to confirm symptom resolution. 4 For treatment failures, evaluate for:

• Persistent BPPV requiring repeat repositioning 4
• Underlying peripheral vestibular disorders 4
• CNS disorders 4
• Need for vestibular rehabilitation therapy (particularly beneficial for elderly patients or those with heightened fall risk) 1

Special Considerations for Elderly Patients

Dizziness increases fall risk 12-fold in elderly patients. 1, 2 BPPV is present in 9% of elderly patients at geriatric evaluation, with three-fourths having fallen within 3 months. 1 Document fall history, assess home safety, and consider vestibular rehabilitation even after successful BPPV treatment. 4, 2