What are the appropriate steps for diagnosing and managing vertigo?

Diagnosing and Managing Vertigo

Initial Clinical Classification by Timing and Triggers

Focus on timing and triggers rather than the patient's subjective description of "dizziness" or "spinning" to categorize vertigo into one of four distinct vestibular syndromes, as this approach is far more diagnostically valuable. 1, 2

• Brief episodic vertigo (seconds to <1 minute): Triggered by head position changes, suggests BPPV—the most common cause accounting for 42% of all vertigo cases 1, 3
• Acute persistent vertigo (days to weeks): Continuous symptoms with nausea/vomiting, suggests vestibular neuritis (41% of cases), labyrinthitis, or posterior circulation stroke 1, 2
• Spontaneous episodic vertigo (minutes to hours): No positional triggers, suggests vestibular migraine (14% of cases), Ménière's disease, or vertebrobasilar TIA 1, 4
• Chronic vestibular syndrome (weeks to months): Suggests medication side effects, anxiety/panic disorder, or posterior fossa mass 1, 2

Critical History Elements

Obtain these specific details to guide your physical examination:

• Duration of each episode: Seconds = BPPV; minutes to hours = vestibular migraine or Ménière's; days = vestibular neuritis or stroke 1, 4
• Triggers: Positional changes = BPPV; standing = orthostatic hypotension; spontaneous = vestibular migraine or Ménière's 1, 2
• Associated symptoms: Hearing loss/tinnitus/aural fullness = Ménière's disease; headache/photophobia/phonophobia = vestibular migraine 1, 2
• Vascular risk factors: Age >50, hypertension, diabetes, atrial fibrillation, prior stroke—these increase stroke risk to 11-25% even with normal neurologic exam 1, 2

Essential Physical Examination Maneuvers

For Brief Episodic Vertigo (Suspected BPPV)

Perform the Dix-Hallpike maneuver bilaterally immediately—this is the gold standard diagnostic test. 1, 2

Positive findings for BPPV (peripheral cause):

• 5-20 second latency before symptoms begin 1, 4
• Torsional, upbeating nystagmus toward the affected ear 1, 4
• Crescendo-decrescendo pattern that resolves within 60 seconds 1, 4
• Fatigues with repeat testing 1, 4

Red flags suggesting central pathology requiring urgent MRI:

• Immediate onset without latency 1, 4
• Purely vertical nystagmus without torsional component 1, 4
• Downbeating nystagmus 1, 4
• Persistent nystagmus that doesn't resolve 1, 4
• Baseline nystagmus present without provocative maneuvers 1, 4

For Acute Persistent Vertigo (Days to Weeks)

Perform the HINTS examination (Head Impulse, Nystagmus, Test of Skew) if you are trained—it has 100% sensitivity for detecting stroke versus only 46% for early MRI. 1, 2

HINTS findings suggesting central cause (stroke):

• Normal head impulse test (abnormal = peripheral) 1, 4
• Direction-changing or vertical nystagmus 1, 4
• Present skew deviation 1, 4

Critical caveat: HINTS is only reliable when performed by trained practitioners; non-expert performance is unreliable. 1

Imaging Decisions: When NOT to Image

Do not order imaging for:

• Brief episodic vertigo with positive Dix-Hallpike test consistent with BPPV and no red flags 1, 2
• Acute persistent vertigo with normal neurologic exam AND peripheral HINTS findings by a trained examiner 1, 2
• Nonspecific dizziness without vertigo, ataxia, or neurologic deficits 1, 2

Common pitfall: CT head has <1% diagnostic yield for isolated dizziness and misses most posterior circulation infarcts—never use CT instead of MRI when stroke is suspected. 1, 2

Imaging Decisions: When MRI IS Indicated

Order MRI brain without contrast immediately for:

• Abnormal neurologic examination 1, 2
• HINTS examination suggesting central cause 1, 2
• High vascular risk patients (age >50, hypertension, diabetes, atrial fibrillation, prior stroke) with acute vestibular syndrome, even with normal neurologic exam—11-25% have posterior circulation stroke 1, 2
• Focal neurological deficits 1, 2
• Sudden unilateral hearing loss 1, 2
• Inability to stand or walk 1, 2
• New severe headache accompanying dizziness 1, 2
• Downbeating or other central nystagmus patterns 1, 2
• Failure to respond to appropriate vestibular treatments 1, 2
• Unilateral or pulsatile tinnitus 1, 2
• Asymmetric hearing loss 1, 2
• Progressive neurologic symptoms 1, 2

Critical fact: 75-80% of patients with acute vestibular syndrome from posterior circulation infarct have NO focal neurologic deficits—normal neurologic exam does not exclude stroke. 1

Treatment by Diagnosis

BPPV (Confirmed by Positive Dix-Hallpike)

Perform canalith repositioning procedures (Epley maneuver) immediately—this is first-line treatment with 80% success after 1-3 treatments and 90-98% success with repeat maneuvers. 1, 2, 4

• Do NOT prescribe vestibular suppressant medications (meclizine) for BPPV—they prevent central compensation and delay recovery 4, 5
• No imaging or laboratory testing needed for typical BPPV 1, 2
• Reassess within 1 month; if symptoms persist, repeat Dix-Hallpike and perform additional repositioning maneuvers 1, 4
• Counsel about 10-18% recurrence risk at one year and fall prevention, especially in elderly 2, 4

Vestibular Neuritis/Labyrinthitis

Initial management includes:

• Vestibular suppressants (meclizine 25-100 mg daily in divided doses) for acute phase only—limit to 3 days maximum 5, 6
• Vestibular rehabilitation therapy as primary intervention once acute phase resolves—significantly improves gait stability compared to medication alone 1, 6

Ménière's Disease

Diagnostic criteria: Episodic vertigo lasting hours + fluctuating low-to-mid frequency sensorineural hearing loss + tinnitus + aural fullness 1, 4

• Obtain audiogram to document hearing loss 1
• Salt restriction and diuretics as first-line treatment 1, 4
• Consider MRI head and internal auditory canal with contrast to exclude vestibular schwannoma 1, 2

Vestibular Migraine

Diagnostic criteria: Episodic vestibular symptoms + migraine by International Headache Society criteria + at least two migraine symptoms during at least two vertiginous episodes 1

Key distinguishing features from Ménière's:

• Stable or absent hearing loss (NOT fluctuating) 1, 4
• Motion intolerance and light sensitivity as triggers 1, 4
• Visual auras commonly described 4

Treatment: Migraine prophylaxis (tricyclic antidepressants, beta blockers, or calcium channel blockers) and lifestyle modifications 1, 6

Special Considerations for Elderly Patients

BPPV is present in 9% of elderly patients referred for geriatric evaluation, with three-fourths having fallen within the prior 3 months. 1

• Dizziness increases fall risk 12-fold in elderly 1
• Check fingerstick glucose immediately—hypoglycemia is the most frequently identified unexpected abnormality 1, 2
• Review medications: antihypertensives, sedatives, anticonvulsants, and psychotropic drugs are leading reversible causes of chronic dizziness 1, 2
• Vestibular rehabilitation therapy is particularly beneficial for elderly patients with heightened fall risk 1, 4

Common Diagnostic Pitfalls to Avoid

• Never rely on patient's description of "spinning" versus "lightheadedness"—focus on timing and triggers instead 1, 2
• Never assume normal neurologic exam excludes stroke—75-80% of posterior circulation infarcts have no focal deficits 1
• Never order routine CT for isolated dizziness—diagnostic yield <1% and misses most posterior circulation infarcts 1, 2
• Never overlook medication side effects—this is one of the most common and reversible causes of chronic dizziness 1, 2
• Never miss vestibular migraine—it's extremely common (14% of all vertigo) but under-recognized, especially in young patients 1, 4
• Never order imaging for typical BPPV with positive Dix-Hallpike and no red flags—it's unnecessary and delays treatment 1, 2