What is the appropriate workup for a patient presenting with dizziness, considering their age, medical history, and specific symptoms?

Workup for Dizziness

The workup for dizziness should be driven by timing and triggers rather than the patient's subjective description, with the physical examination (particularly the Dix-Hallpike maneuver and HINTS examination) being far more valuable than imaging or laboratory testing in most cases. 1

Initial Clinical Assessment

Categorize by Timing Pattern (Most Critical Step)

The American Academy of Otolaryngology-Head and Neck Surgery emphasizes that classification by timing is more diagnostically valuable than vague patient descriptions 1, 2:

• Brief episodic vertigo (seconds to <1 minute): Triggered by head position changes → suggests BPPV, which accounts for 42% of all vertigo cases 1
• Acute persistent vertigo (days to weeks): Constant symptoms → suggests vestibular neuritis (41% of peripheral vertigo), labyrinthitis, or posterior circulation stroke 1
• Spontaneous episodic vertigo (minutes to hours): No positional trigger → suggests vestibular migraine (14% of cases) or Ménière's disease 1
• Chronic vestibular syndrome (weeks to months): Persistent symptoms → suggests medication side effects, anxiety/panic disorder, or posttraumatic vertigo 1

Essential Historical Details

Focus on these specific elements rather than asking patients to describe their "dizziness" 1:

• Associated symptoms: Hearing loss, tinnitus, and aural fullness point to Ménière's disease 1; headache, photophobia, and phonophobia suggest vestibular migraine 1
• Triggers: Positional changes (BPPV), standing up (orthostatic hypotension), or spontaneous onset 1
• Vascular risk factors: Age >50, hypertension, atrial fibrillation, diabetes, prior stroke increase stroke risk to 11-25% even with normal neurologic exam 1
• Medication review: Antihypertensives, sedatives, anticonvulsants, and psychotropic drugs are leading causes of chronic dizziness 1
• Migraine history: Vestibular migraine is extremely common but under-recognized, particularly in young patients 1, 2

Physical Examination (The Cornerstone of Diagnosis)

Mandatory Maneuvers Based on Presentation

For brief episodic vertigo:

• Dix-Hallpike maneuver (gold standard for BPPV): Look for latency period of 5-20 seconds, torsional upbeating nystagmus toward the affected ear, and symptoms that increase then resolve within 60 seconds 1
• Perform bilaterally to identify the affected side 1

For acute persistent vertigo:

• HINTS examination (Head-Impulse, Nystagmus, Test of Skew): When performed by trained practitioners, this has 100% sensitivity for detecting stroke versus only 46% for early MRI 1
  • Normal head impulse test, direction-changing or vertical nystagmus, and present skew deviation suggest central (stroke) cause 1
  • Abnormal head impulse test, unidirectional horizontal nystagmus, and absent skew deviation suggest peripheral cause 1

For all patients:

• Orthostatic vital signs (check immediately and at 3 minutes for delayed orthostatic hypotension) 1
• Full neurologic examination including cranial nerves, cerebellar testing, and gait assessment 1, 2
• Observation for spontaneous nystagmus patterns 1

Diagnostic Testing Strategy

When Imaging is NOT Indicated

Do not order imaging for 1:

• Brief episodic vertigo with positive Dix-Hallpike test and no additional concerning features (typical BPPV)
• 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

When MRI Brain Without Contrast IS Indicated

Order MRI immediately for these red flags 1:

• Focal neurological deficits on examination
• Sudden unilateral hearing loss
• Inability to stand or walk
• Downbeating nystagmus or other central nystagmus patterns
• New severe headache accompanying dizziness
• HINTS examination suggesting central cause
• High vascular risk patients with acute vestibular syndrome (even with normal neurologic exam, as 11-25% have posterior circulation stroke) 1
• Unilateral or pulsatile tinnitus
• Asymmetric hearing loss
• Progressive neurologic symptoms

Role of CT Imaging

CT head has extremely limited utility 1:

• Diagnostic yield <1% for isolated dizziness
• Sensitivity only 20-40% for posterior circulation infarcts
• Should NOT be used instead of MRI when stroke is suspected
• May be appropriate only as initial imaging in acute settings before MRI becomes available

Laboratory Testing

Laboratory testing has very low yield 1:

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

Audiologic Testing

Obtain comprehensive audiologic examination for 1:

• Unilateral tinnitus
• Persistent symptoms
• Associated hearing difficulties
• Suspected Ménière's disease (to document low-to-mid frequency sensorineural hearing loss)

Treatment Based on Diagnosis

BPPV (Most Common Cause)

Canalith repositioning procedures (Epley maneuver) are first-line treatment 1:

• 80% success after 1-3 treatments
• 90-98% success with repeat maneuvers
• No imaging or medication needed for typical cases
• Reassess within one month to document resolution

Vestibular Neuritis/Labyrinthitis

• Vestibular rehabilitation therapy should be initiated as soon as possible 2
• Short-term vestibular suppressants only for acute symptom management 3

Vestibular Migraine

• Migraine prophylaxis and lifestyle modifications 1, 2
• Motion intolerance and light sensitivities help differentiate from Ménière's 1

Ménière's Disease

• Salt restriction and diuretics 1
• Intratympanic treatments for refractory cases 4

Medication-Induced Dizziness

• Medication review and adjustment is one of the most common and reversible causes 1

Critical Pitfalls to Avoid

Common diagnostic errors 1:

• Relying on patient's description of "spinning" versus "lightheadedness" instead of focusing on timing and triggers
• Assuming normal neurologic exam excludes stroke: 75-80% of patients with acute vestibular syndrome from posterior circulation infarct have no focal neurologic deficits
• Ordering imaging for straightforward BPPV: This delays treatment unnecessarily
• Skipping the Dix-Hallpike maneuver: This is the gold standard diagnostic test
• Using CT instead of MRI when stroke is suspected: CT misses most posterior circulation infarcts
• Overlooking vestibular migraine: Extremely common but under-recognized, particularly in young patients 1, 2
• Failing to distinguish fluctuating hearing loss (Ménière's) from stable/absent hearing loss (vestibular migraine) 1

Special Populations

Elderly Patients

• Dizziness increases fall risk 12-fold 4
• BPPV is present in 9% of elderly patients referred for geriatric evaluation, with three-fourths having fallen within prior 3 months 4
• Conduct fall risk screening using standardized questions 4
• Consider vestibular rehabilitation therapy, which significantly improves gait stability 4