Initial Evaluation and Management of Dizziness
For a patient presenting with dizziness, begin by categorizing the vestibular syndrome based on timing and triggers—not the patient's subjective description of "spinning" versus "lightheadedness"—then perform targeted bedside examination maneuvers (Dix-Hallpike or HINTS) rather than ordering routine imaging or laboratory tests. 1, 2
Clinical Triage Framework
The most critical first step is classifying dizziness into one of three timing-based categories, as this determines your entire diagnostic approach 1, 2, 3:
Triggered Episodic Vestibular Syndrome
- Duration: Seconds to minutes, provoked by head position changes 4, 2
- Most likely diagnosis: Benign Paroxysmal Positional Vertigo (BPPV), accounting for 42% of all vertigo cases 2
- Immediate action: Perform bilateral Dix-Hallpike maneuver looking for 5-20 second latency, torsional upbeating nystagmus toward the affected ear, and symptoms that crescendo then resolve within 60 seconds 1, 2
- Management: If positive, perform Epley maneuver immediately (80% success after 1-3 treatments, 90-98% with repeat maneuvers) 1, 2
- Imaging: None indicated for typical BPPV with positive Dix-Hallpike and normal neurologic exam 4, 1, 2
Acute Vestibular Syndrome (AVS)
- Duration: Continuous vertigo lasting days to weeks 1, 2
- Highest stroke risk category: 25% have posterior circulation stroke, rising to 75% in high vascular risk patients 2
- Immediate action: Perform HINTS examination (Head-Impulse, Nystagmus, Test of Skew) if trained—this has 100% sensitivity for stroke versus 46% for early MRI 1, 2, 5
- HINTS findings suggesting stroke: Normal head impulse test, direction-changing or vertical nystagmus, present skew deviation 2, 5
- Critical pitfall: 75-80% of posterior circulation stroke patients have NO focal neurologic deficits on standard examination 2, 5
- Imaging decision algorithm:
Spontaneous Episodic Vestibular Syndrome
- Duration: Minutes to hours, no positional trigger 1, 2
- Key diagnoses: Vestibular migraine (14% of all vertigo), Ménière's disease 2
- Distinguishing features:
- Imaging: Not routinely indicated unless unilateral/pulsatile tinnitus or asymmetric hearing loss present 1, 2, 5
Red Flags Requiring Immediate MRI and Neurology Consultation
Any of these findings mandate urgent MRI brain without contrast 2, 5:
- Focal neurologic deficits (diplopia, dysarthria, facial numbness, limb weakness) 5
- Sudden unilateral hearing loss 2, 5
- Inability to stand or walk independently 2, 5
- New severe headache accompanying dizziness 2, 5
- Downbeating or direction-changing nystagmus 2, 5
- Normal head impulse test in acute vestibular syndrome 5
- Unilateral or pulsatile tinnitus 2, 5
Laboratory Testing: When NOT to Order
Routine laboratory testing has extremely low diagnostic yield and is not indicated for most dizzy patients 1:
- Only check: Fingerstick glucose immediately (hypoglycemia is the most common unexpected finding) 2
- Consider basic metabolic panel only if: History suggests dehydration, orthostatic hypotension, or electrolyte disturbance 1
- Avoid: Routine comprehensive laboratory panels—they rarely change management 2
Imaging Guidelines: The Critical Distinction
CT Head: Almost Never Appropriate
- Diagnostic yield <1% for isolated dizziness 4, 1, 5
- Sensitivity only 20-40% for causative pathology 4, 5
- Misses most posterior circulation infarcts 4, 5
- Do not use CT as a substitute for MRI when stroke is suspected 5
MRI Brain Without Contrast: When Indicated
- High vascular risk + acute vestibular syndrome (even with normal exam) 1, 2, 5
- Any red flag features listed above 2, 5
- Diagnostic yield 4% in isolated dizziness, 12% when neurologic findings present 1
- Far superior to CT for posterior circulation pathology 4, 1, 5
CTA Head/Neck: Very Limited Role
- Diagnostic yield only 3% in isolated dizziness 4
- Sensitivity 14%, adds no information beyond noncontrast CT 4
- Only appropriate for: Pulsatile tinnitus to evaluate vascular malformations 2
Management by Diagnosis
BPPV (Most Common)
- Epley maneuver first-line, no medications needed 1, 2, 6, 7
- Reassess within one month 2
- Counsel about 50% recurrence risk and fall prevention 2
Vestibular Neuritis
- Vestibular suppressants (short-term only, <3 days to avoid delaying central compensation) 6, 7
- Vestibular rehabilitation therapy 6, 7
Ménière's Disease
- Salt restriction, diuretics 2, 6
- Audiogram to document low-to-mid frequency sensorineural hearing loss 2
Vestibular Migraine
- Migraine prophylaxis and lifestyle modifications 2, 7
- Vestibular rehabilitation for persistent symptoms 7
Persistent Dizziness After Initial Treatment
- Vestibular rehabilitation therapy significantly improves gait stability, especially in elderly patients 2
- Failure to respond to appropriate treatment is a red flag for central pathology 2, 5
Critical Pitfalls to Avoid
- Do not rely on patient descriptions of "spinning" versus "lightheadedness"—these are unreliable 2, 5
- Do not assume normal neurologic exam excludes stroke—most posterior circulation strokes have no focal deficits 2, 5
- Do not order routine imaging for isolated dizziness with typical peripheral features—yield is <1% 4, 1, 5
- Do not skip bedside testing—Dix-Hallpike and HINTS provide more diagnostic value than imaging in most cases 1, 2, 5
- Do not use HINTS if untrained—accuracy drops significantly when performed by non-experts 2
Special Populations
Elderly Patients
- BPPV present in 9% of elderly patients referred for geriatric evaluation 2
- Dizziness increases fall risk 12-fold 2
- May not describe classic "spinning" vertigo even with serious pathology 5
- Medication review is essential—antihypertensives, sedatives, anticonvulsants are leading reversible causes 1, 2