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

Workup of Dizziness

Begin by classifying dizziness into one of four temporal patterns—brief episodic (seconds), acute persistent (days), spontaneous episodic (minutes to hours), or chronic (weeks to months)—because timing and triggers are far more diagnostically valuable than the patient's subjective description of "spinning" versus "lightheadedness." 1

Initial Clinical Assessment

Critical History Elements

• Duration of episodes distinguishes etiologies: seconds suggest BPPV, minutes to hours suggest vestibular migraine or Ménière's disease, and days to weeks suggest vestibular neuritis or posterior circulation stroke 1
• Triggers such as head position changes point to BPPV, while spontaneous episodes suggest vestibular migraine or Ménière's disease 1
• Associated symptoms including hearing loss, tinnitus, or aural fullness strongly suggest Ménière's disease, whereas headache with photophobia and phonophobia suggest vestibular migraine 2, 1
• Vascular risk factors (age >50, hypertension, diabetes, atrial fibrillation, prior stroke) dramatically increase posterior circulation stroke probability to 75% in acute vestibular syndrome 1
• Medication review is essential, as antihypertensives, sedatives, anticonvulsants, and psychotropic drugs are leading causes of chronic dizziness 1

Physical Examination Maneuvers

For brief episodic vertigo triggered by position changes, perform the Dix-Hallpike maneuver bilaterally—this is more diagnostic than any imaging or laboratory test for BPPV. 2, 1 Look for:

• Latency period of 5-20 seconds before symptoms begin 1
• Torsional upbeating nystagmus toward the affected ear 1
• Vertigo and nystagmus that crescendo then resolve within 60 seconds 2, 1

For acute persistent vertigo lasting days, perform the HINTS examination (Head Impulse, Nystagmus, Test of Skew) if you are trained in this technique. 1 When performed by trained practitioners, HINTS has 100% sensitivity for detecting stroke versus 46% for early MRI 1. However, emergency physicians achieve inadequate sensitivity, so do not rely on HINTS alone in the emergency department 1.

HINTS findings suggesting central (stroke) cause:

• Normal head impulse test (abnormal is reassuring for peripheral cause) 1
• Direction-changing or vertical nystagmus 1
• Skew deviation present 1

Laboratory Testing

Laboratory testing is not routinely indicated for dizziness—diagnosis relies on history, bedside maneuvers, and selective neuroimaging, not blood work. 3

Limited exceptions where labs may be appropriate:

• Fingerstick glucose immediately if altered mental status (hypoglycemia is the most frequently identified unexpected abnormality) 1
• Basic metabolic panel only if orthostatic hypotension or dehydration suspected 3
• Syphilis serology if sensory ataxia with risk factors 3

Imaging Decisions

When Imaging Is NOT Indicated

No imaging is needed for:

• Brief episodic vertigo with positive Dix-Hallpike test and no additional concerning features 1, 3
• Acute persistent vertigo with normal neurologic exam and HINTS examination showing peripheral features (when performed by trained examiner) 1
• Chronic nonspecific dizziness without vertigo, ataxia, or neurologic deficits 1

When Imaging IS Indicated

Order MRI brain without contrast (not CT) for:

• Abnormal neurologic examination with focal deficits 1, 4
• HINTS examination suggesting central cause 1, 4
• High vascular risk patients (age >50, hypertension, diabetes, atrial fibrillation, prior stroke) with acute vestibular syndrome, even with normal neurologic exam—11-25% harbor posterior circulation stroke 1
• Unilateral or pulsatile tinnitus 1
• Asymmetric hearing loss 1, 4
• Progressive neurologic symptoms suggesting mass lesion 1

MRI with diffusion-weighted imaging has 4% diagnostic yield versus <1% for CT head. 1, 3 CT misses the majority of posterior circulation infarcts with only 20-40% sensitivity 1, 3. CT should not substitute for MRI when stroke is suspected 1.

Red Flags Requiring Urgent Evaluation

Immediate MRI and neurologic consultation are mandatory for:

• Focal neurological deficits on examination 1
• Sudden unilateral hearing loss 1
• Inability to stand or walk 1
• Downbeating nystagmus or other central nystagmus patterns 1
• New severe headache accompanying dizziness 1
• Failure to respond to appropriate vestibular treatments 1

Treatment Based on Diagnosis

BPPV (Positive Dix-Hallpike)

Perform canalith repositioning procedures (Epley maneuver) immediately—this achieves 80% success after 1-3 treatments and 90-98% success with repeat maneuvers. 1 No imaging or medication is needed for typical cases 1. Reassess within one month and counsel about 50% recurrence risk over 5 years 1.

Vestibular Neuritis

Vestibular suppressants (antiemetics, benzodiazepines) are limited to the acute phase only, followed by early vestibular rehabilitation 1.

Ménière's Disease

Requires comprehensive audiometry documenting fluctuating low-to-mid frequency sensorineural hearing loss 2, 1. Treatment includes salt restriction, diuretics, and potentially intratympanic gentamicin for refractory cases 1.

Vestibular Migraine

Migraine prophylaxis and lifestyle modifications are first-line 2, 1. Vestibular migraine accounts for 14% of all vertigo cases but is extremely under-recognized 1.

Persistent Dizziness After Initial Treatment

Vestibular rehabilitation therapy is the primary intervention for persistent dizziness that has failed initial treatment, significantly improving gait stability compared to medication alone. 1 This is particularly beneficial for elderly patients or those with heightened fall risk 1.

Critical Pitfalls to Avoid

• Do not rely on patient descriptions of "spinning" versus "lightheadedness"—focus on timing, triggers, and associated symptoms instead 1
• Do not assume a normal neurologic exam excludes stroke—75-80% of patients with acute vestibular syndrome from posterior circulation infarct have no focal neurologic deficits 1
• Do not order CT head for isolated dizziness—it has <1% diagnostic yield and misses most posterior circulation infarcts 1, 3
• Do not perform HINTS examination if you are not trained—non-experts achieve inadequate sensitivity, and a falsely reassuring result delays appropriate imaging 1
• Do not order routine comprehensive laboratory panels—they rarely change management in isolated dizziness 3