What is the appropriate evaluation and management for a patient presenting with giddiness?

Evaluation of Giddiness

For a patient presenting with giddiness, categorize the symptom by timing and triggers rather than the patient's subjective description, perform targeted bedside examinations (Dix-Hallpike maneuver, HINTS examination, orthostatic vitals), and reserve imaging only for red flag features suggesting central pathology. 1, 2

Initial Clinical Assessment

History Taking: Focus on Timing and Triggers

• Duration of episodes is the most diagnostically valuable feature: seconds (<1 minute) suggests BPPV, minutes to hours suggests vestibular migraine or Ménière's disease, and days to weeks suggests vestibular neuritis or stroke 1, 2

• Triggers help narrow the differential: positional changes suggest BPPV, standing suggests orthostatic hypotension, and spontaneous onset suggests vestibular migraine, Ménière's disease, or stroke 1, 2

• Associated symptoms provide critical diagnostic clues:

  • Hearing loss, tinnitus, or aural fullness point to Ménière's disease 1, 2
  • Headache with photophobia and phonophobia suggest vestibular migraine 2
  • Neurological symptoms (diplopia, dysarthria, numbness, weakness) indicate central causes requiring urgent evaluation 1

• Avoid relying on the patient's description of "spinning" versus "lightheadedness"—these subjective terms do not reliably distinguish peripheral from central causes 2

Physical Examination: Targeted Bedside Tests

• Observe for spontaneous nystagmus in all patients with giddiness 1

• Perform the Dix-Hallpike maneuver for suspected BPPV: look for 5-20 second latency, torsional upbeating nystagmus toward the affected ear, and symptoms resolving within 60 seconds 1, 2

• Perform the HINTS examination (Head Impulse, Nystagmus, Test of Skew) for acute persistent vertigo lasting days to weeks—this has 100% sensitivity for detecting stroke when performed by trained practitioners, superior to early MRI (46% sensitivity) 1, 2

• Check orthostatic vital signs to evaluate for orthostatic hypotension as a cause of presyncope-type giddiness 3

• Complete neurologic examination to identify focal deficits suggesting central pathology 1

Imaging Decisions

When Imaging is NOT Indicated

• No imaging is needed for brief episodic vertigo with typical BPPV features and positive Dix-Hallpike test 1, 2

• No imaging is needed for acute persistent vertigo with normal neurologic exam and HINTS examination consistent with peripheral vertigo (when performed by a trained examiner) 1, 2

• Routine imaging has very low yield in isolated dizziness—CT detects causative pathology in less than 1% of cases 1, 2

When Imaging IS Indicated

• MRI brain without contrast is recommended 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% may have posterior circulation stroke 1, 2
  • Unilateral or pulsatile tinnitus 1, 2
  • Asymmetric hearing loss 1, 2
  • Progressive neurologic symptoms 1, 2

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

Red Flags Requiring Urgent Evaluation

• Focal neurological deficits on examination 1, 2

• Sudden unilateral hearing loss 1, 2

• Inability to stand or walk 1, 2

• Downbeating nystagmus or other central nystagmus patterns 1, 2

• New severe headache accompanying dizziness—mandates immediate imaging and neurologic consultation 1, 2

• Failure to respond to appropriate vestibular treatments 1, 2

Common Diagnostic Pitfalls to Avoid

• Do not assume a normal neurologic exam excludes stroke—75-80% of patients with acute vestibular syndrome from posterior circulation infarct have no focal neurologic deficits 2

• Do not use CT instead of MRI when stroke is suspected—CT misses many posterior circulation infarcts 2

• Do not order routine comprehensive laboratory panels—they rarely change management in patients with isolated dizziness who have returned to baseline neurologic status 1

• Check fingerstick glucose immediately—hypoglycemia is the most frequently identified unexpected abnormality in dizzy patients 1

• Do not order neuroimaging or vestibular testing for patients who meet diagnostic criteria for BPPV with a positive Dix-Hallpike test and no additional concerning features 1

Treatment Based on Diagnosis

• For BPPV: Perform canalith repositioning procedures (Epley maneuver) as first-line treatment—80% success after 1-3 treatments, 90-98% success with repeat maneuvers 1, 2

• For vestibular neuritis: Consider steroids 3

• For Ménière's disease: Salt restriction, diuretics, and in some cases intratympanic treatments 1

• For vestibular migraine: Migraine prophylaxis and lifestyle modifications 1

• For orthostatic hypotension: Alpha agonists, mineralocorticoids, or lifestyle changes 3