What is the recommended workup for a patient presenting with dizziness?

Workup for Dizziness

Categorize dizziness by timing and triggers—not by the patient's subjective description—to determine the specific vestibular syndrome, then perform targeted bedside examination and selective imaging only when red flags are present. 1, 2

Step 1: Categorize by Timing and Triggers

Ignore vague patient descriptions like "spinning" versus "lightheadedness"—these are unreliable. 3 Instead, classify into one of four vestibular syndromes based on objective timing patterns:

Acute Vestibular Syndrome (AVS)

• Constant dizziness lasting days to weeks 1, 2
• Requires HINTS examination (see below) 1
• 25% are posterior circulation strokes 4
• Critical pitfall: 75-80% of posterior circulation strokes have NO focal neurologic deficits, so normal neuro exam does NOT exclude stroke 1, 3

Triggered Episodic Vestibular Syndrome

• Seconds to <1 minute, triggered by specific head positions 2, 3
• Suggests BPPV (42% of all vertigo cases) 2
• Requires Dix-Hallpike maneuver 1, 2

Spontaneous Episodic Vestibular Syndrome

• Minutes to hours, no positional trigger 2, 3
• Suggests vestibular migraine (14% of cases) or Ménière's disease 1, 2

Chronic Vestibular Syndrome

• Weeks to months of persistent symptoms 2, 3
• Consider medication side effects (leading reversible cause), anxiety/panic disorder, or posttraumatic vertigo 1, 3

Step 2: Essential History Elements

Duration and Onset

• Seconds → BPPV 2, 3
• Minutes to hours → vestibular migraine or Ménière's 2, 3
• Days to weeks → vestibular neuritis or stroke 2, 3

Associated Symptoms

• Hearing loss, tinnitus, aural fullness → Ménière's disease 1, 2
• Headache, photophobia, phonophobia → vestibular migraine 2, 3
• Neurologic symptoms (diplopia, dysarthria, numbness, weakness) → central cause 2

Vascular Risk Factors

• Age >50, hypertension, atrial fibrillation, diabetes, prior stroke → increases stroke risk to 11-25% even with normal exam 1, 2

Medication Review

• Antihypertensives, sedatives, anticonvulsants, psychotropic drugs are leading causes of chronic dizziness 3

Step 3: Physical Examination

For ALL Patients

• Observe for spontaneous nystagmus 2
• Complete neurologic examination including cranial nerves, cerebellar testing, gait assessment 1
• Orthostatic vital signs (standing from supine suggests cardiovascular cause, not vestibular) 3

For Triggered Episodic (Suspected BPPV)

Perform Dix-Hallpike maneuver bilaterally 1, 2:

• Positive findings: 5-20 second latency, torsional upbeating nystagmus toward affected ear, symptoms resolve within 60 seconds 2, 3
• If positive: diagnose BPPV, perform Epley maneuver immediately (80% success after 1-3 treatments), no imaging needed 1, 2, 3

For Acute Vestibular Syndrome

Perform HINTS examination (only if trained—unreliable when performed by non-experts) 1, 2:

• Head Impulse: normal (corrective saccade absent) suggests central cause 1, 3
• Nystagmus: direction-changing or vertical suggests central cause 1, 3
• Test of Skew: present skew deviation suggests central cause 1, 3
• HINTS has 100% sensitivity for stroke when performed by trained practitioners (superior to early MRI at 46% sensitivity) 1, 2, 3

Step 4: Imaging Decisions

NO Imaging Indicated For:

• Typical BPPV with positive Dix-Hallpike and no red flags 1, 2
• AVS with normal neurologic exam, HINTS consistent with peripheral vertigo by trained examiner, and low vascular risk 2, 3
• Chronic dizziness without red flags 3

MRI Brain Without Contrast Indicated For:

• Abnormal neurologic examination 1, 2
• HINTS examination suggesting central cause 1, 2
• High vascular risk patients with AVS, even with normal exam (11-25% stroke risk) 1, 2
• Unilateral or pulsatile tinnitus 1, 2
• Asymmetric hearing loss 1, 2
• Any red flag (see below) 1, 2

Critical Imaging Pitfall

Never use CT instead of MRI when stroke is suspected—CT has <1% diagnostic yield for isolated dizziness and misses most posterior circulation infarcts (sensitivity only 10-20%) 4, 2, 3. MRI with diffusion-weighted imaging has 4% diagnostic yield versus <1% for CT 2, 3.

Step 5: Red Flags Requiring Urgent MRI and Neurology Consultation

• Focal neurological deficits 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 (thunderclap pattern) 1, 3
• Progressive neurologic symptoms 2, 3
• Failure to respond to appropriate vestibular treatments 1, 3

Step 6: Laboratory Testing

Generally NOT indicated for most dizziness 5, 6. Consider only:

• Fingerstick glucose immediately (hypoglycemia is most common unexpected abnormality) 3
• Basic metabolic panel only if history/exam suggests specific abnormalities 3
• Avoid routine comprehensive lab panels—they rarely change management 3

Step 7: Treatment Based on Diagnosis

BPPV

• Epley maneuver (canalith repositioning): 80% success after 1-3 treatments, 90-98% with repeat maneuvers 1, 2, 3
• Reassess within one month 3
• Counsel on 10-18% recurrence at 1 year, up to 36% long-term 1
• Fall risk increases 12-fold, especially in elderly 1, 3

Ménière's Disease

• Salt restriction and diuretics 1, 6
• Intratympanic treatments for refractory cases 1

Vestibular Migraine

• Migraine prophylaxis and lifestyle modifications 1, 3

Vestibular Neuritis

• Vestibular rehabilitation therapy (primary intervention for persistent symptoms) 3, 6
• Vestibular suppressants only for acute phase 6

Common Pitfalls to Avoid

• Relying on symptom quality ("spinning" vs "lightheadedness") instead of timing and triggers 1, 3
• Assuming normal neurologic exam excludes stroke (75-80% of posterior circulation strokes have no focal deficits) 1, 3
• Overuse of imaging for clear peripheral causes 2
• Failing to perform Dix-Hallpike when indicated 1
• Using CT instead of MRI for suspected stroke 2, 3
• Not assessing fall risk in elderly patients with vestibular disorders 1, 3
• Using HINTS when not trained—accuracy depends on examiner experience 4, 1