What is the appropriate management for a patient experiencing vertigo and dizziness?

Management of Vertigo and Dizziness

The appropriate management of vertigo and dizziness depends on classifying the patient into one of four temporal patterns—triggered episodic (<1 minute), spontaneous episodic (minutes to hours), acute vestibular syndrome (days), or chronic (weeks to months)—followed by targeted physical examination and selective imaging only when red flags are present. 1, 2

Initial Classification by Timing and Triggers

The first step is to abandon asking patients to describe their dizziness quality (spinning vs lightheadedness) and instead focus on timing and triggers, which are far more diagnostically useful 1, 2:

• Triggered episodic vertigo (seconds to <1 minute): Brief episodes provoked by specific head position changes suggest BPPV (42% of all vertigo cases), superior canal dehiscence, or perilymphatic fistula 1, 2
• Spontaneous episodic vertigo (minutes to hours): Unprovoked episodes lasting 20 minutes to hours suggest vestibular migraine (14% of cases), Ménière's disease, or vertebrobasilar insufficiency 1, 2
• Acute vestibular syndrome (days): Continuous severe vertigo lasting days suggests vestibular neuritis (41% of peripheral vertigo), labyrinthitis, or posterior circulation stroke 3, 1
• Chronic vertigo (weeks to months): Persistent symptoms suggest medication side effects (leading reversible cause), anxiety disorder, or posterior fossa mass 1, 2

Critical History Elements

Obtain these specific details rather than vague descriptions 1:

• Auditory symptoms: Hearing loss, tinnitus, or aural fullness suggest Ménière's disease (fluctuating hearing loss) versus vestibular migraine (stable hearing) 1, 2
• Migrainous features: Headache, photophobia, and phonophobia point to vestibular migraine, which accounts for 14% of all vertigo but is extremely under-recognized 1, 2
• Vascular risk factors: Age >50, hypertension, diabetes, atrial fibrillation, or prior stroke increase stroke risk to 11-25% even with normal neurologic exam 1, 4
• Medication review: Antihypertensives, sedatives, anticonvulsants, and psychotropic drugs are the leading reversible cause of chronic dizziness 1, 2

Targeted Physical Examination

For Triggered Episodic Vertigo (Suspected BPPV)

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

• Latency period of 5-20 seconds before symptoms begin
• Torsional, upbeating nystagmus toward the affected ear
• Vertigo and nystagmus that increase then resolve within 60 seconds 1, 2

If Dix-Hallpike is negative but history suggests BPPV, perform the Supine Roll Test to diagnose lateral canal BPPV (10-15% of BPPV cases) 4.

For Acute Vestibular Syndrome

Perform the HINTS examination (Head-Impulse, Nystagmus, Test of Skew), which has 100% sensitivity for detecting stroke when performed by trained practitioners, compared to only 46% sensitivity for early MRI 1, 2.

Central vertigo findings (requiring urgent imaging) 1, 2:

• Normal head impulse test (abnormal is reassuring for peripheral cause)
• Direction-changing or vertical nystagmus
• Present skew deviation

Red Flags Requiring Urgent Neuroimaging

Order MRI brain without contrast immediately for any of these features 1, 2, 4:

• Focal neurological deficits on examination
• Sudden unilateral hearing loss
• Inability to stand or walk
• Downbeating or other central nystagmus patterns
• New severe headache accompanying dizziness
• Progressive neurologic symptoms
• HINTS examination suggesting central cause
• High vascular risk patients with acute vestibular syndrome (even with normal neurologic exam)

Critical pitfall: 75-80% of patients with acute vestibular syndrome from posterior circulation infarct have no focal neurologic deficits, so normal neurologic exam does not exclude stroke in high-risk patients 1.

Imaging Strategy

When NO Imaging Is Indicated

• Brief episodic vertigo with typical BPPV features and positive Dix-Hallpike test 3, 1
• Acute persistent vertigo with normal neurologic exam and HINTS consistent with peripheral vertigo by trained examiner 1, 2
• Nonspecific dizziness without vertigo, ataxia, or neurologic deficits 1

When Imaging IS Indicated

MRI brain without contrast is the preferred modality for 1, 4:

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

CT head has extremely low diagnostic yield (<1%) for isolated dizziness and misses most posterior circulation infarcts with only 20-40% sensitivity 1. CT should not be used instead of MRI when stroke is suspected 1.

Treatment Based on Diagnosis

BPPV (Most Common Cause)

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

• 80% success after 1-3 treatments
• 90-98% success with repeat maneuvers if initial treatment fails 1, 2
• No imaging or medication is needed for typical cases 1

Reassess within one month to document resolution or persistence, and counsel about recurrence risk and fall risk 1.

Vestibular Neuritis

• Limited course of vestibular suppressants (e.g., meclizine 25-100 mg daily in divided doses) only during acute attacks for symptomatic relief 2, 5
• Vestibular rehabilitation therapy is the primary intervention for persistent symptoms, significantly improving gait stability compared to medication alone 1

Important: Warn patients about drowsiness with meclizine and caution against driving or operating machinery; avoid alcohol 5.

Ménière's Disease

• Salt restriction and diuretics 6
• Educate on dietary modifications: avoid excessive caffeine, alcohol, and nicotine; maintain hydration 2
• Audiometry to document low-to-mid frequency sensorineural hearing loss 1

Vestibular Migraine

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

Medication-Induced Chronic Dizziness

Review and adjust antihypertensives, sedatives, anticonvulsants, and psychotropic medications—this is one of the most common and reversible causes 1, 2.

Laboratory Testing

No routine blood tests are recommended for diagnosing BPPV (85-95% of vertigo cases), as the diagnosis is fundamentally clinical 4.

Reserve laboratory testing for specific scenarios 4:

• Audiometry: For auditory symptoms suggesting Ménière's disease or other inner ear pathology
• Autoimmune panels: For bilateral fluctuating progressive hearing loss potentially steroid-responsive
• Serologic tests: For suspected infectious causes (Lyme disease, otosyphilis) with severe otalgia, fever, or sudden bilateral hearing loss

Common Pitfalls to Avoid

• Do not rely on patient's description of "spinning" vs "lightheadedness"—focus on timing and triggers instead 1, 2
• Do not assume normal neurologic exam excludes stroke in acute vestibular syndrome, especially in high vascular risk patients 1, 2
• Do not perform Dix-Hallpike when Romberg is positive—this indicates central pathology requiring imaging first 2, 4
• Do not order CT instead of MRI when stroke is suspected—CT misses most posterior circulation infarcts 1
• Do not order routine imaging for isolated dizziness—diagnostic yield is <1% and most findings are incidental 1
• Do not misdiagnose central causes as BPPV—CNS disorders masquerading as BPPV are found in 3% of treatment failures 2, 4

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, with three-fourths having fallen within the prior 3 months 1. Document fall history, circumstances, and injuries sustained, and consider home safety assessment and supervision if elderly and frail 1.