What is the appropriate approach to evaluating and managing a patient who presents with dizziness?

Approach to Dizziness

Categorize dizziness by timing and triggers—not by the patient's vague description of "spinning" versus "lightheadedness"—to distinguish benign peripheral causes from dangerous central pathology like stroke. 1, 2, 3, 4

Initial Classification by Timing and Triggers

The most effective diagnostic framework divides dizziness into four vestibular syndromes based on duration and precipitating factors 1, 2, 3:

1. Triggered Episodic Vestibular Syndrome (seconds to <1 minute)

• Triggered by head position changes suggests Benign Paroxysmal Positional Vertigo (BPPV), which accounts for 42% of all vertigo cases 1, 3
• Perform the Dix-Hallpike maneuver bilaterally looking for: 5-20 second latency, torsional upbeating nystagmus toward the affected ear, symptoms resolving within 60 seconds 1, 2, 5
• No imaging is needed for typical BPPV with positive Dix-Hallpike test 1, 2, 5

2. Spontaneous Episodic Vestibular Syndrome (minutes to hours)

• Vestibular migraine (14% of all vertigo cases): Look for current/past migraine history, headache with photophobia/phonophobia during episodes 1, 3
• Ménière's disease: Characterized by fluctuating hearing loss, tinnitus, and aural fullness in the affected ear 1, 6, 7
• Key distinguishing feature: Ménière's has fluctuating hearing loss versus stable/absent hearing loss in vestibular migraine 1

3. Acute Vestibular Syndrome (days to weeks of constant symptoms)

• Vestibular neuritis (41% of peripheral vertigo): Unidirectional horizontal nystagmus persisting without positional changes 1, 3
• Posterior circulation stroke (25% of acute vestibular syndrome cases, rising to 75% in high vascular risk cohorts) 1, 3
• Critical point: 75-80% of patients with posterior circulation infarct have NO focal neurologic deficits on exam 1

4. Chronic Vestibular Syndrome (weeks to months)

• Medication side effects are the leading reversible cause—review antihypertensives, sedatives, anticonvulsants, psychotropic drugs 1, 2
• Anxiety/panic disorder is extremely common and often overlooked 1, 6
• Posttraumatic vertigo following head trauma 1

Essential Physical Examination Maneuvers

For Triggered Episodic Symptoms (Suspected BPPV)

Dix-Hallpike maneuver is the gold standard diagnostic test 1, 2, 5:

• Positive findings: 5-20 second latency, torsional upbeating nystagmus toward affected ear, symptoms resolve within 60 seconds 1, 5
• Perform bilaterally to assess both posterior canals 1
• Supine roll test for horizontal canal BPPV 2, 3, 4

For Acute Vestibular Syndrome (Suspected Stroke vs. Vestibular Neuritis)

HINTS examination (Head-Impulse, Nystagmus, Test of Skew) has 100% sensitivity for detecting stroke when performed by trained practitioners, compared to only 46% sensitivity for early MRI 1, 2, 5:

• Normal head impulse test suggests central (stroke) 1
• Direction-changing or vertical nystagmus suggests central 1
• Present skew deviation suggests central 1

Critical caveat: HINTS is less reliable when performed by non-experts 1

Red Flags Requiring Urgent MRI and Neurologic Consultation

Immediate imaging is mandatory for 1, 2:

• 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
• Progressive neurologic symptoms

Imaging Decisions: When to Image and What to Order

Do NOT Image

• Brief episodic vertigo with typical BPPV features and positive Dix-Hallpike test 1, 2, 5
• 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

MRI Brain Without Contrast (Preferred Imaging)

Order for 1, 2:

• Abnormal neurologic examination
• HINTS examination suggesting central cause
• High vascular risk patients (age >50, hypertension, diabetes, atrial fibrillation, prior stroke) with acute vestibular syndrome—even with normal neurologic exam, as 11-25% may have posterior circulation stroke 1, 2
• Unilateral or pulsatile tinnitus
• Asymmetric hearing loss
• Progressive neurologic symptoms

MRI has 4% diagnostic yield in isolated dizziness versus <1% for CT, with ischemic stroke being the most common finding (70% of positive cases) 1, 2

MRI Head and Internal Auditory Canal WITH and WITHOUT Contrast

Order for 1:

• Chronic recurrent vertigo with unilateral hearing loss or tinnitus to exclude vestibular schwannoma
• Suspected Ménière's disease requiring definitive diagnosis

CT Head: Very Limited Role

CT has <1% diagnostic yield for isolated dizziness and sensitivity of only 20-40% for detecting causative pathology 1, 2:

• CT misses most posterior circulation infarcts 1, 2
• May be appropriate before MRI in acute settings when stroke is suspected, but should NOT replace MRI 1

CT Temporal Bone

Order for 8:

• Conductive hearing loss without mass lesion in middle ear cavity
• Suspected superior semicircular canal dehiscence (perform reconstructions along Pöschl plane)
• Suspected ossicular erosion or otosclerosis

Treatment Based on Diagnosis

BPPV

Canalith repositioning procedures (Epley maneuver) are first-line treatment 1, 2, 5, 7:

• 80% success after 1-3 treatments 1, 5
• 90-98% success with repeat maneuvers 1, 2, 5
• No medications are needed for typical BPPV 1
• Counsel patients about 10-18% recurrence risk at one year, up to 36% long-term 2

Vestibular Neuritis

• Vestibular suppressant medications (short-term only) 7
• Vestibular rehabilitation therapy is primary intervention for persistent symptoms, significantly improves gait stability compared to medication alone 1, 7

Ménière's Disease

• Salt restriction and diuretics 1, 6, 7
• Intratympanic dexamethasone or gentamicin for refractory cases 6
• Obtain audiogram to document low-to-mid frequency sensorineural hearing loss 1

Vestibular Migraine

• Migraine prophylaxis and lifestyle modifications 1, 7
• Motion intolerance and light sensitivities help differentiate from Ménière's 1

Medication-Induced Chronic Dizziness

• Medication review and adjustment is one of the most common and reversible causes 1, 2

Critical Pitfalls to Avoid

1. Do NOT rely on patient's description of "spinning" versus "lightheadedness"—focus on timing and triggers instead 1, 2, 3, 4

2. Do NOT assume normal neurologic exam excludes stroke—75-80% of posterior circulation infarct patients have no focal deficits 1

3. Do NOT order routine imaging for isolated dizziness—it has very low yield (<1% for CT) and most findings are incidental 1, 2

4. Do NOT use CT instead of MRI when stroke is suspected—CT misses most posterior circulation infarcts 1, 2

5. Do NOT order comprehensive vestibular testing or neuroimaging for straightforward BPPV with positive Dix-Hallpike test 1

6. Do NOT overlook vestibular migraine—it accounts for 14% of all vertigo cases but is extremely under-recognized, particularly in young patients 1

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 prior 3 months 1
• Document number of falls in past year, circumstances, and injuries sustained 1
• Vestibular rehabilitation therapy is particularly beneficial for elderly patients with heightened fall risk 1
• Check fingerstick glucose immediately—hypoglycemia is the most frequently identified unexpected abnormality in elderly dizzy patients 1