What is the appropriate evaluation and management approach for a patient presenting with dizziness, considering their demographic, medical history, and potential underlying conditions?

Evaluation of Dizziness: A Structured Clinical Approach

The evaluation of dizziness should begin by classifying the presentation into one of four temporal patterns—brief episodic, acute persistent, spontaneous episodic, or chronic vestibular syndrome—based on timing and triggers rather than the patient's subjective description, as this classification directly guides physical examination and distinguishes benign peripheral causes from dangerous central pathology like stroke. 1

Initial Classification by Timing Pattern

The most critical first step is determining the temporal pattern, which has far greater diagnostic value than vague patient descriptions of "spinning" or "lightheadedness" 1, 2:

• Brief episodic vertigo (seconds to <1 minute): Triggered by head position changes, strongly suggests BPPV, which accounts for 42% of all vertigo cases 1
• Acute persistent vertigo (days to weeks): Constant symptoms suggest vestibular neuritis (41% of peripheral vertigo), labyrinthitis, or posterior circulation stroke (25% of acute vestibular syndrome cases) 1
• Spontaneous episodic vertigo (minutes to hours): Suggests vestibular migraine (14% of all vertigo cases, though extremely under-recognized) or Ménière's disease 1
• Chronic vestibular syndrome (weeks to months): Consider medication side effects (leading reversible cause), anxiety/panic disorder, or posttraumatic vertigo 1

Critical Associated Symptoms to Elicit

Do not rely on whether the patient describes "spinning" versus "lightheadedness"—this distinction is unreliable and misleading. 1, 2 Instead, focus on these specific features:

• Headache with photophobia and phonophobia: Strongly suggests vestibular migraine 1
• Hearing loss, tinnitus, and aural fullness: Points to Ménière's disease (fluctuating hearing loss) versus vestibular migraine (stable/absent hearing loss) 1
• Focal neurological symptoms (dysarthria, diplopia, facial numbness, limb weakness): Red flags for central pathology requiring urgent imaging 2
• New severe headache: Mandates immediate imaging and neurologic consultation for possible hemorrhage or dissection 2

Essential Physical Examination Maneuvers

For Brief Episodic Vertigo (Suspected BPPV)

Perform the Dix-Hallpike maneuver bilaterally—this is the gold standard diagnostic test and should never be skipped. 1, 3 Diagnostic criteria include:

• 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

For Acute Persistent Vertigo (Suspected Stroke vs. Vestibular Neuritis)

The HINTS examination (Head-Impulse, Nystagmus, Test of Skew) has 100% sensitivity for detecting posterior circulation stroke when performed by trained practitioners, compared to only 46% sensitivity for early MRI. 1 However, when performed by non-experts, results are less reliable 1.

Components suggesting central (stroke) cause:

• Normal head impulse test (corrective saccade absent) 1, 2
• Direction-changing or vertical nystagmus 1
• Present skew deviation 1

Components suggesting peripheral cause:

• Abnormal head impulse test (corrective saccade present) 1
• Unidirectional horizontal nystagmus 1
• Absent skew deviation 1

Additional Examination Elements

• Orthostatic vital signs to rule out orthostatic hypotension 3, 4
• Thorough neurologic exam including cranial nerves, cerebellar testing, and gait assessment 3
• Observation for spontaneous nystagmus patterns (downbeating or central patterns are red flags) 2

Red Flags Requiring Urgent Neuroimaging (MRI Brain Without Contrast)

A critical pitfall: 75-80% of patients with acute vestibular syndrome from posterior circulation infarction have NO focal neurologic deficits on standard examination—therefore, a normal neurologic exam does NOT exclude stroke. 1, 2

Immediate MRI indications 1, 2:

• Focal neurological deficits (diplopia, dysarthria, facial numbness, limb weakness)
• Sudden unilateral hearing loss
• Inability to stand or walk independently
• Downbeating nystagmus or other central nystagmus patterns
• New severe headache accompanying dizziness
• Abnormal HINTS examination suggesting central cause
• High vascular risk patients (age >50, hypertension, diabetes, atrial fibrillation, prior stroke) with acute vestibular syndrome—even with normal neurologic exam, as 11-25% may have posterior circulation stroke 1

Imaging Decisions: When NOT to Image

No imaging is indicated for: 1

• Brief episodic vertigo with typical BPPV features and positive Dix-Hallpike test
• Acute persistent vertigo with normal neurologic exam AND HINTS examination consistent with peripheral vertigo by a trained examiner
• Nonspecific dizziness without vertigo, ataxia, or neurologic deficits

Routine imaging for isolated dizziness has extremely low yield (<1% for CT) and most findings are incidental. 1

Imaging Decisions: When Imaging IS Indicated

MRI brain without contrast (NOT CT) is the appropriate study when imaging is needed 1:

• CT head has only 20-40% sensitivity for detecting causative pathology in dizziness and misses most posterior circulation infarcts 1, 2
• MRI with diffusion-weighted imaging has 4% diagnostic yield versus <1% for CT 1
• CT should not be used instead of MRI when stroke is suspected 1, 2

MRI head and internal auditory canal WITH and WITHOUT contrast for 1:

• Chronic recurrent vertigo with unilateral hearing loss or tinnitus (to exclude vestibular schwannoma)
• Unilateral or pulsatile tinnitus 2
• Asymmetric hearing loss 1

Treatment Based on Diagnosis

BPPV (Most Common Cause)

Canalith repositioning procedures (Epley maneuver) are first-line treatment, with 80% success after 1-3 treatments and 90-98% success with repeat maneuvers. 1, 3 No imaging or medication is needed for typical cases 1. The Epley maneuver has 80.5% negative Dix-Hallpike by day 7, compared to only 25% with Brandt-Daroff exercises 1.

Vestibular Neuritis

Vestibular rehabilitation therapy should be initiated as soon as possible and is the primary intervention for persistent dizziness, significantly improving gait stability compared to medication alone 1, 3.

Vestibular Migraine

Migraine prophylaxis and lifestyle modifications are essential 1, 3. This diagnosis is extremely common but under-recognized, particularly in young patients 1, 3.

Ménière's Disease

Salt restriction, diuretics, and in some cases intratympanic treatments 1. Audiograms should document low-to-mid frequency sensorineural hearing loss 1.

Laboratory Testing

Laboratory testing has very low yield in patients with dizziness who have returned to baseline neurologic status. 1

• Check fingerstick glucose immediately—hypoglycemia is the most frequently identified unexpected abnormality 1
• Consider basic metabolic panel only if history or examination suggests specific abnormalities 1
• Avoid routine comprehensive laboratory panels, as they rarely change management 1

Special Considerations for Elderly Patients

Dizziness increases fall risk 12-fold in elderly patients, and BPPV is present in 9% of elderly patients referred for geriatric evaluation, with three-fourths having fallen within the prior 3 months. 1 Document fall history, circumstances, and injuries sustained 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 descriptions of "spinning" versus "lightheadedness" instead of focusing on timing and triggers 1, 2, 3
• Assuming normal neurologic exam excludes stroke—75-80% of posterior circulation strokes have no focal deficits 1, 2, 3
• Ordering CT instead of MRI when stroke is suspected—CT misses most posterior circulation infarcts 1, 2
• Ordering imaging for straightforward BPPV—this delays treatment unnecessarily 3
• Skipping the Dix-Hallpike maneuver—the gold standard diagnostic test 3
• Overlooking vestibular migraine—extremely common but under-recognized, especially in young patients 1, 3
• Overlooking medication side effects—a leading reversible cause of chronic dizziness, particularly antihypertensives, sedatives, anticonvulsants, and psychotropic drugs 1