What is the most appropriate diagnostic approach and treatment plan for a patient with vertigo, considering their age, medical history of previous ear or head injuries, and symptoms such as impaired balance and gait?

Diagnostic Approach to Vertigo

For a patient with vertigo, impaired balance, gait disturbance, and history of ear or head injuries, immediately perform the Dix-Hallpike maneuver to diagnose BPPV—the most common cause of vertigo—and if positive, treat with the Epley maneuver without any imaging or laboratory testing. 1, 2

Initial Clinical Assessment: Define the Vertigo Pattern

Characterize the precise duration and triggers of vertigo episodes, as this single feature distinguishes most causes:

• Seconds-only duration (<1 minute) triggered by head position changes indicates BPPV 1, 2
• Minutes to hours suggests vestibular migraine or Ménière's disease 2
• Days to weeks of constant symptoms indicates vestibular neuritis or posterior circulation stroke 2

Identify associated symptoms that point to specific diagnoses:

• Hearing loss, tinnitus, and aural fullness suggest Ménière's disease 1, 2
• Headache with photophobia and phonophobia suggests vestibular migraine 2
• Sudden unilateral hearing loss is a red flag requiring urgent neuroimaging 2

In elderly patients or those with prior head trauma, BPPV is present in 9% of geriatric patients, with three-fourths having fallen within 3 months prior to diagnosis. 3 The history of ear or head injuries increases BPPV likelihood, as trauma is a known precipitating factor. 1

Essential Bedside Physical Examination

Perform the Dix-Hallpike maneuver bilaterally—this is the gold standard diagnostic test for BPPV:

• Positive findings include 5-20 second latency, torsional upbeating nystagmus toward the affected ear, and symptoms that crescendo then resolve within 60 seconds 1, 2
• A positive Dix-Hallpike test confirms BPPV and no imaging or laboratory testing is needed 1, 2

For patients with acute persistent vertigo (days to weeks), perform the HINTS examination if trained:

• HINTS (Head Impulse, Nystagmus, Test of Skew) has 100% sensitivity for detecting posterior circulation stroke when performed by trained practitioners, compared to only 46% for early MRI 2
• Central features requiring urgent imaging include: normal head impulse test, direction-changing or vertical nystagmus, downbeating nystagmus, and present skew deviation 2, 4

Critical pitfall: 75-80% of patients with posterior circulation stroke present with isolated vertigo WITHOUT focal neurologic deficits on standard examination, so absence of focal signs does not rule out stroke. 2, 4

Imaging Decisions: When NOT to Image

Do not order imaging for:

• Brief episodic vertigo with positive Dix-Hallpike test and typical BPPV features 2
• Acute persistent vertigo with normal neurologic exam and HINTS examination consistent with peripheral vertigo by a trained examiner 2
• Straightforward BPPV cases, as imaging has no diagnostic value and delays treatment 1, 2

CT head has extremely low diagnostic yield (<1%) for isolated dizziness and misses most posterior circulation infarcts—it should not be used instead of MRI when stroke is suspected. 2

Imaging Decisions: When Imaging IS Required

Order MRI brain without contrast for:

• High vascular risk patients (age >50, hypertension, diabetes, prior stroke) with acute vestibular syndrome, even with normal neurologic examination, as 11-25% may have posterior circulation stroke 2
• Abnormal neurologic examination or HINTS examination suggesting central cause 2
• Focal neurological deficits, inability to stand or walk, or central nystagmus patterns 2
• New severe headache accompanying dizziness—this mandates immediate imaging and neurologic consultation 2
• Unilateral or pulsatile tinnitus, asymmetric hearing loss, or sudden hearing loss 2

MRI with diffusion-weighted imaging is far superior to CT (4% diagnostic yield vs <1% for CT) and is essential for detecting posterior circulation infarcts. 2

Treatment Algorithm Based on Diagnosis

For confirmed BPPV (positive Dix-Hallpike):

• Perform canalith repositioning procedures (Epley maneuver) immediately—this has 80% success after 1-3 treatments and 90-98% success with repeat maneuvers 1, 2
• Do not prescribe medications for typical BPPV, as they are unnecessary and only delay definitive treatment 1
• Meclizine may be used only for immediate symptom relief during acute distress (nausea), but is not a treatment for BPPV 5

Post-treatment counseling:

• Patients may experience motion sickness-type symptoms and mild instability for hours to days after successful treatment 1
• Recurrence risk is 10-18% at 1 year and up to 36% long-term 1
• In elderly patients with impaired balance and gait, dizziness increases fall risk 12-fold—assess home safety, consider supervision until resolved, and refer for vestibular rehabilitation if symptoms persist 2, 3

For persistent dizziness after initial BPPV treatment:

• Refer for vestibular rehabilitation therapy, which significantly improves gait stability compared to medication alone and is particularly beneficial for elderly patients or those with heightened fall risk 2

Special Considerations for Patients with Prior Head or Ear Injuries

History of trauma is associated with BPPV development, but also raises concern for:

• Perilymphatic fistula (if trauma was recent and severe) 6
• Post-traumatic vertigo, which can persist chronically with symptoms including vertigo, disequilibrium, tinnitus, and headache 2
• Superior canal dehiscence (if symptoms include pressure-induced vertigo or autophony) 2

If BPPV treatment fails or presentation is atypical, consider audiologic testing and possible MRI to exclude structural pathology. 2

Red Flags Requiring Urgent Evaluation

Immediately obtain MRI brain without contrast and neurologic consultation for:

• Focal neurological deficits on examination 2
• Sudden unilateral hearing loss 2
• Inability to stand or walk 2
• Downbeating nystagmus or other central nystagmus patterns 2, 4
• New severe headache accompanying dizziness 2
• Progressive neurologic symptoms 2
• Failure to respond to appropriate vestibular treatments 2

Common Diagnostic Pitfalls to Avoid

Do not rely on patient's description of "spinning" versus "lightheadedness"—instead focus on timing, duration, and triggers. 2 Elderly patients often describe atypical "vestibular disturbance" rather than classic spinning sensations. 3, 4

Do not assume normal neurologic exam excludes stroke—up to 80% of posterior circulation stroke patients with acute vestibular syndrome have no focal neurologic deficits. 2, 4

Do not skip the Dix-Hallpike maneuver in favor of imaging—it provides more diagnostic value than imaging for most vertigo cases and allows immediate treatment. 2, 4

Do not order comprehensive vestibular testing for straightforward BPPV—it is unnecessary, costly, and delays definitive treatment. 2