What is the recommended approach to evaluating and managing a patient presenting with dizziness?

Approach to Dizziness

Initial Classification by Timing and Triggers

Categorize dizziness based on timing and triggers—not the patient's vague description of "spinning" versus "lightheadedness"—to guide your diagnostic pathway. 1, 2

The American Academy of Otolaryngology-Head and Neck Surgery recommends classifying dizziness into four distinct vestibular syndromes 1, 2, 3:

• Triggered Episodic Vestibular Syndrome: Seconds to <1 minute, provoked by head position changes—think BPPV (most common cause of peripheral vertigo, 42% of cases) 1, 2
• Spontaneous Episodic Vestibular Syndrome: Minutes to hours, no positional trigger—consider vestibular migraine (14% of all vertigo) or Ménière's disease 1, 2
• Acute Vestibular Syndrome: Days to weeks of continuous symptoms—vestibular neuritis (41% of peripheral vertigo) or posterior circulation stroke (25% of acute vestibular syndrome cases) 1, 2
• Chronic Vestibular Syndrome: Weeks to months—medication side effects (leading reversible cause), anxiety/panic disorder, or posttraumatic vertigo 2

Critical History Elements

Focus on these specific details rather than accepting vague descriptions 1, 2, 3:

• Duration: Seconds = BPPV; minutes-to-hours = vestibular migraine or Ménière's; days-to-weeks = vestibular neuritis or stroke 1, 2
• Triggers: Positional changes (BPPV), standing (orthostatic hypotension), spontaneous (vestibular migraine, Ménière's) 1, 2
• Associated symptoms:
  • Hearing loss, tinnitus, or aural fullness strongly suggest Ménière's disease, labyrinthitis, or vestibular schwannoma 1, 2
  • Headache with photophobia/phonophobia suggests vestibular migraine 2
  • Focal neurologic symptoms mandate urgent stroke evaluation 1, 2

Essential Bedside Examination

For Triggered Episodic Vertigo (Suspected BPPV)

Perform the Dix-Hallpike maneuver bilaterally as your gold standard diagnostic test 1, 2, 3:

• Positive test criteria: 5-20 second latency, torsional upbeating nystagmus toward the affected ear, symptoms resolving within 60 seconds 1, 3
• If positive with typical features: No imaging or laboratory testing needed—proceed directly to treatment 2, 3

For Acute Vestibular Syndrome (Continuous Vertigo)

The HINTS examination (Head-Impulse, Nystagmus, Test of Skew) is more sensitive than early MRI for detecting posterior circulation stroke (100% vs 46% sensitivity) when performed by trained practitioners 1, 2:

• Central features requiring urgent imaging: Normal head impulse test, direction-changing or vertical nystagmus, present skew deviation 2
• Peripheral features: Abnormal head impulse test (corrective saccade), unidirectional horizontal nystagmus, absent skew deviation 1, 2

Critical pitfall: 75-80% of patients with posterior circulation stroke have NO focal neurologic deficits on standard examination—never assume a normal neurologic exam excludes stroke 1, 2

Orthostatic Vital Signs

Check orthostatic blood pressure in all patients, but recognize that delayed orthostatic hypotension (occurring beyond 3 minutes) may be missed by standard testing 2

Imaging Decisions: When NOT to Image

No imaging is indicated for 2, 3:

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

Common pitfall: Routine imaging for isolated dizziness has extremely low yield (<1% for CT) and most findings are incidental 2

Imaging Decisions: When Imaging IS Mandatory

Order MRI brain without contrast immediately for 2, 3:

• Abnormal neurologic examination 2, 3
• HINTS examination suggesting central cause 2, 3
• 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) 2, 3
• Focal neurological deficits 2
• Sudden unilateral hearing loss 2
• Inability to stand or walk 2
• Downbeating or other central nystagmus patterns 2
• New severe headache accompanying dizziness 2
• Progressive neurologic symptoms 2

Order MRI head and internal auditory canal WITH and WITHOUT contrast for 2:

• Unilateral or pulsatile tinnitus (exclude vestibular schwannoma or vascular malformation) 1, 2
• Asymmetric hearing loss 2
• Chronic recurrent vertigo with unilateral hearing loss or tinnitus 2

Critical imaging principle: CT head has very low diagnostic yield (<1%) and misses most posterior circulation infarcts—never use CT instead of MRI when stroke is suspected 2, 3

Laboratory Testing

Laboratory testing has very low yield in dizziness 2:

• Check fingerstick glucose immediately—hypoglycemia is the most frequently identified unexpected abnormality 2
• Consider basic metabolic panel only if history or examination suggests specific abnormalities 2
• Avoid routine comprehensive laboratory panels—they rarely change management 2

Treatment Based on Diagnosis

BPPV (Most Common Cause)

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, 3:

• No medications needed for typical BPPV 2
• Counsel patients about 10-18% recurrence risk at one year, up to 36% long-term 3
• Special consideration for elderly: BPPV is present in 9% of elderly patients referred for geriatric evaluation, with three-fourths having fallen within prior 3 months—dizziness increases fall risk 12-fold 2

Vestibular Neuritis

• Vestibular suppressant medications for acute symptom relief 4
• Vestibular rehabilitation therapy 4
• Steroids may be beneficial 5

Ménière's Disease

• Salt restriction and diuretics 2, 4
• Intratympanic dexamethasone or gentamicin for refractory cases 5
• Obtain audiogram to document low-to-mid frequency sensorineural hearing loss 2

Vestibular Migraine

• Migraine prophylaxis and lifestyle modifications 2
• Diagnostic consideration: Vestibular migraine is extremely common but under-recognized, particularly in young patients—always ask about current/past migraine history and family history 2

Medication-Induced Chronic Dizziness

Review and adjust medications—this is a leading reversible cause of chronic vestibular syndrome 2:

• Antihypertensives, sedatives, anticonvulsants, psychotropic drugs 2

Persistent Dizziness After Initial Treatment

Refer for vestibular rehabilitation therapy—this significantly improves gait stability compared to medication alone, particularly beneficial for elderly patients or those with heightened fall risk 2

Common Diagnostic Pitfalls to Avoid

• Never rely on patient descriptions of "spinning" versus "lightheadedness"—focus on timing, triggers, and duration instead 1, 2
• Never assume normal neurologic exam excludes stroke—75-80% of posterior circulation infarct patients have no focal deficits 1, 2
• Never use HINTS examination results from non-expert examiners to rule out stroke—reliability is significantly reduced 2
• Never order CT when stroke is suspected—it misses most posterior circulation infarcts 2
• Never order neuroimaging or vestibular testing for straightforward BPPV with positive Dix-Hallpike—it delays treatment unnecessarily 2
• Never overlook vestibular migraine—it accounts for 14% of all vertigo cases but remains under-recognized 2