What is the recommended evaluation and first‑line management for acute vertigo in an adult without known neurologic disease?

Acute Vertigo: Evaluation and First-Line Management

For an adult presenting with acute vertigo and no known neurologic disease, immediately classify the syndrome by timing and triggers—not by the patient's description of "spinning"—then perform the Dix-Hallpike maneuver for episodic triggered vertigo or the HINTS examination for continuous acute vertigo, and treat confirmed BPPV immediately with the Epley maneuver without ordering any imaging or laboratory tests. 1, 2

Initial Classification by Timing and Triggers

The American Academy of Otolaryngology-Head and Neck Surgery emphasizes that timing and triggers are far more diagnostically useful than the patient's subjective description of their dizziness. 1, 2, 3 Classify into one of four syndromes:

• Triggered episodic vestibular syndrome (seconds to <1 minute): Brief episodes provoked by specific head position changes—suggests BPPV (42% of all vertigo cases), superior canal dehiscence, or perilymphatic fistula. 1, 2
• Spontaneous episodic vestibular syndrome (minutes to hours): Episodes lasting 20 minutes to hours without provocation—suggests vestibular migraine (14% of cases), Ménière's disease, or vertebrobasilar TIA. 1, 2
• Acute vestibular syndrome (days to weeks): Continuous severe vertigo with nausea, vomiting, and intolerance to head motion—suggests vestibular neuritis (41% of peripheral vertigo), labyrinthitis, or posterior circulation stroke (25% of acute vestibular syndrome cases). 1, 2
• Chronic vestibular syndrome (weeks to months): Persistent symptoms—suggests anxiety disorders, medication side effects, or posterior fossa masses. 1, 2

Targeted History: Specific Details That Matter

Do not accept vague descriptions. 4, 2 Elicit:

• Auditory symptoms: Hearing loss, tinnitus, or aural fullness point to Ménière's disease (fluctuating hearing loss) versus vestibular migraine (stable or absent hearing loss). 1, 2
• Migrainous features: Headache, photophobia, phonophobia, or visual aura during at least two vertiginous episodes suggest vestibular migraine—an extremely common but under-recognized diagnosis. 1, 2
• Vascular risk factors: Age >50, hypertension, diabetes, atrial fibrillation, or prior stroke increase the likelihood of posterior circulation stroke to 11–25% even with a normal neurologic exam. 4, 2
• Medication review: Antihypertensives, sedatives, anticonvulsants, and psychotropic drugs are a leading reversible cause of chronic vestibular syndrome. 1, 2

Physical Examination: Execute Specific Maneuvers

For Triggered Episodic Vertigo (Suspected BPPV)

Perform the Dix-Hallpike maneuver bilaterally as the gold standard diagnostic test. 1, 2, 3 Positive findings for posterior canal BPPV include:

• Latency period of 5–20 seconds before symptom onset 1, 2
• Torsional and upbeating nystagmus toward the affected ear 1, 2
• Crescendo-decrescendo pattern that resolves within 60 seconds 1, 2
• Fatigability with repeated testing 1

Red flags indicating central pathology (do NOT perform Epley; order urgent MRI instead):

• Immediate onset without latency 1, 2
• Purely vertical nystagmus (upbeating or downbeating) without torsional component 1, 2
• Persistent nystagmus that does not fatigue 1, 2
• Baseline nystagmus present without provocative maneuvers 1, 2

For Acute Vestibular Syndrome (Continuous Vertigo)

Perform the HINTS examination (Head-Impulse, Nystagmus, Test of Skew) if trained—it has 100% sensitivity for detecting stroke versus 46% for early MRI. 4, 2 Components suggesting central (stroke) cause:

• Normal head impulse test (abnormal test suggests peripheral) 1, 2
• Direction-changing or purely vertical nystagmus 1, 2
• Skew deviation present 1, 2

Critical caveat: HINTS is less reliable when performed by non-experts; if uncertain, obtain MRI brain with diffusion-weighted imaging for high-risk patients. 4, 2

Red Flags Requiring Urgent MRI Brain (Without and With Contrast)

Any of the following mandate immediate diffusion-weighted MRI, not CT: 1, 4, 2

• Severe postural instability with falling 1, 2
• New-onset severe headache with vertigo 1, 2
• Any focal neurologic deficits (dysarthria, dysmetria, dysphagia, limb weakness, cranial nerve palsies) 1, 2
• Downbeating nystagmus on Dix-Hallpike without torsional component 1, 2
• Sudden unilateral hearing loss 1, 2
• Inability to stand or walk 1, 2
• Failure to respond to appropriate peripheral vertigo treatments 1, 2

Note: Approximately 75–80% of patients with acute vestibular syndrome from posterior circulation infarct have no focal neurologic deficits on standard exam—do not assume a normal exam excludes stroke in high-risk patients. 4, 2

When NOT to Order Imaging or Laboratory Tests

Do not obtain imaging for: 1, 4, 2

• Brief episodic vertigo with typical BPPV features and positive Dix-Hallpike test 1, 4
• Acute persistent vertigo with normal neurologic exam and HINTS consistent with peripheral vertigo by a trained examiner 4, 2
• Diagnosed BPPV without red flags 1

Do not order routine laboratory tests (CBC, BMP) for typical BPPV, which accounts for 85–95% of vertigo cases. 2 The diagnostic yield of CT head in isolated dizziness is <1%, and CT misses most posterior circulation infarcts. 1, 4

First-Line Treatment by Diagnosis

Benign Paroxysmal Positional Vertigo (BPPV)

Perform canalith repositioning procedures (Epley maneuver) immediately upon diagnosis—this is first-line therapy with 80% success after 1–3 treatments and 90–98% success with repeated maneuvers. 1, 2, 3

• Do not prescribe vestibular suppressant medications for BPPV—they prevent central compensation and are not indicated. 1, 2
• Do not impose postprocedural postural restrictions—they do not improve outcomes. 1
• If symptoms persist, repeat the Dix-Hallpike test to confirm ongoing BPPV and perform additional repositioning maneuvers. 1

Vestibular Neuritis (Acute Vestibular Syndrome, Peripheral)

• Offer a limited course of vestibular suppressants only during acute attacks for symptomatic relief (e.g., meclizine, dimenhydrinate). 2, 3
• Initiate vestibular rehabilitation therapy early—it significantly improves gait stability compared to medication alone, particularly in elderly patients or those with heightened fall risk. 1, 3

Ménière's Disease (Spontaneous Episodic Vertigo with Fluctuating Hearing Loss)

• Dietary sodium restriction and adequate hydration 1, 2
• Diuretics (e.g., hydrochlorothiazide with potassium supplementation) 1, 3
• Vestibular rehabilitation therapy 1
• Obtain audiometry to document low-to-mid frequency sensorineural hearing loss 1

Vestibular Migraine (Spontaneous Episodic Vertigo with Stable Hearing)

• Migraine prophylaxis (e.g., beta-blockers, tricyclic antidepressants, topiramate) and lifestyle modifications (trigger avoidance, sleep hygiene, stress management) 1, 2
• Distinguish from Ménière's by the presence of stable or absent hearing loss (not fluctuating) and migraine features during at least two vertiginous episodes. 1

Common Pitfalls to Avoid

• Do not rely on the patient's description of "spinning" versus "lightheadedness"—focus on timing and triggers instead. 4, 2, 3
• Do not assume a normal neurologic exam excludes stroke in acute vestibular syndrome, especially in patients >50 years with vascular risk factors. 4, 2
• Do not order CT head for suspected posterior circulation stroke—it has only 20–40% sensitivity; MRI with diffusion-weighted imaging is mandatory. 1, 4
• Do not overlook vestibular migraine—it accounts for 14% of all vertigo cases but is extremely under-recognized, particularly in young women. 1, 2
• Do not perform the Dix-Hallpike maneuver if the Romberg test is positive—this indicates central pathology requiring imaging first. 2
• Do not misdiagnose cerebellar stroke as peripheral vertigo—approximately 10% of cerebellar strokes present similarly to peripheral vestibular disorders. 1

Follow-Up

Reassess patients within 1 month after initial observation or treatment to document resolution or persistence of symptoms. 1 Repeat the Dix-Hallpike test if symptoms persist to confirm ongoing BPPV or identify other vestibular pathology. 1 Counsel patients about recurrence risk (BPPV recurs in up to 50% at 5 years), fall risk (12-fold increase in elderly), and the importance of returning promptly if symptoms recur. 1, 2