What is the recommended initial assessment and management for a patient presenting with dizziness?

Initial Assessment and Management of Dizziness

Categorize the patient by timing and triggers—not by symptom quality—to guide your physical examination and distinguish benign peripheral vestibular disorders from life-threatening central causes like stroke. 1, 2, 3

Step 1: Classify Into One of Three Vestibular Syndromes

The traditional approach of asking patients to describe their dizziness as "spinning" versus "lightheadedness" is unreliable and should be abandoned. 1 Instead, use this framework:

Triggered Episodic Vestibular Syndrome

• Duration: Seconds to <1 minute 1, 2
• Trigger: Specific head position changes 1, 2
• Most likely diagnosis: BPPV (accounts for 42% of all vertigo cases) 1
• Immediate action: Perform Dix-Hallpike maneuver bilaterally 4, 1, 3

Acute Vestibular Syndrome (AVS)

• Duration: Days to weeks of constant symptoms 1, 2
• Trigger: None—spontaneous onset 1
• Critical differential: Vestibular neuritis (41% of peripheral vertigo) versus posterior circulation stroke (25% of AVS cases, rising to 75% in high-risk patients) 1, 3
• Immediate action: Perform HINTS examination if you are trained; otherwise obtain urgent MRI 1, 2, 3

Spontaneous Episodic Vestibular Syndrome

• Duration: Minutes to hours 1, 2
• Trigger: None 1
• Most likely diagnoses: Vestibular migraine (14% of all vertigo) or Ménière's disease 1, 2
• Immediate action: Assess for associated symptoms (see below) 1, 2

Step 2: Obtain Targeted History

Duration-Specific Questions

• Seconds → BPPV 1, 2, 3
• Minutes to hours → Vestibular migraine or Ménière's 1, 2, 3
• Days to weeks → Vestibular neuritis or stroke 1, 2, 3

Associated Symptoms That Change Management

• Hearing loss + tinnitus + aural fullness → Ménière's disease 1, 2, 3
• Headache + photophobia + phonophobia → Vestibular migraine 1, 2, 3
• Sudden unilateral hearing loss → Red flag requiring urgent MRI 1, 3
• New severe headache → Red flag mandating immediate imaging and neurology consultation 1, 3

Vascular Risk Stratification (Critical for AVS)

Document age >50, hypertension, diabetes, atrial fibrillation, or prior stroke—these patients have up to 75% risk of posterior circulation stroke even with normal neurologic exam. 1, 3

Medication Review

Antihypertensives, sedatives, anticonvulsants, and psychotropic drugs are leading reversible causes of chronic dizziness. 1

Step 3: Perform Targeted Physical Examination

For Triggered Episodic Syndrome (Suspected BPPV)

Dix-Hallpike Maneuver (perform bilaterally): 4, 1, 3

• Positive findings: 5-20 second latency, torsional upbeating nystagmus toward affected ear, symptoms resolve within 60 seconds 4, 1
• If negative, perform supine roll test for lateral canal BPPV 4, 1

For Acute Vestibular Syndrome

HINTS Examination (only if you are trained—untrained practitioners have inadequate accuracy): 1, 2, 3

• Head Impulse: Normal (corrective saccade absent) = central cause 1, 3
• Nystagmus: Direction-changing or vertical = central cause 1, 3
• Test of Skew: Present skew deviation = central cause 1, 3

Critical pitfall: 75-80% of patients with posterior circulation stroke have NO focal neurologic deficits, so a normal neurologic exam does NOT exclude stroke. 1, 3

Complete Neurologic Examination for All Patients

Include cranial nerves, cerebellar testing (finger-to-nose, heel-to-shin, rapid alternating movements), and gait assessment. 2, 3

Fall Risk Assessment in Elderly

Ask: "Have you fallen in the past year? How many times? Do you feel unsteady?" Dizziness increases fall risk 12-fold in elderly patients. 1, 3

Step 4: Imaging Decisions

Do NOT Image

• Brief episodic vertigo with positive Dix-Hallpike and typical BPPV features 4, 1, 2
• AVS with normal neurologic exam AND peripheral HINTS by trained examiner AND low vascular risk 1, 2

Obtain MRI Brain Without Contrast (NOT CT)

• Abnormal neurologic examination 1, 2, 3
• HINTS suggesting central cause 1, 2, 3
• High vascular risk patients with AVS (even with normal exam—11-25% have stroke) 1, 3
• Unilateral or pulsatile tinnitus 1, 2, 3
• Asymmetric hearing loss 1, 2, 3
• Focal neurological deficits 1, 3
• Inability to stand or walk 1, 3
• Downbeating or central nystagmus patterns 1, 3

Why MRI, not CT: CT has <1% diagnostic yield for isolated dizziness and misses most posterior circulation infarcts (sensitivity only 10-20%), while MRI with diffusion-weighted imaging has 4% diagnostic yield. 1, 3

Step 5: Treatment Based on Diagnosis

BPPV

Immediately perform canalith repositioning (Epley maneuver): 80% success after 1-3 treatments, 90-98% with repeat maneuvers. 4, 1, 2, 3 Do NOT prescribe vestibular suppressants (antihistamines, benzodiazepines)—they are ineffective and delay central compensation. 4 Reassess within 1 month and counsel about 10-18% recurrence at 1 year. 4, 3

Vestibular Neuritis (Peripheral AVS)

Vestibular suppressants only for acute phase (first 48-72 hours), then early vestibular rehabilitation to promote central compensation. 1

Vestibular Migraine

Migraine prophylaxis (beta-blockers, tricyclics, topiramate) and lifestyle modifications (sleep hygiene, trigger avoidance). 1, 2, 3

Ménière's Disease

Salt restriction (<2g sodium/day) and diuretics; intratympanic dexamethasone or gentamicin for refractory cases. 1, 2, 3

Posterior Circulation Stroke

Activate stroke protocol immediately, urgent neurology consultation, and admit for stroke workup. 2, 3

Vestibular Rehabilitation

For persistent dizziness failing initial treatment, particularly in elderly patients or those with CNS disorders—significantly improves gait stability compared to medication alone. 1, 3

Common Pitfalls to Avoid

• Relying on patient's description of "spinning" versus "lightheadedness"—focus on timing and triggers instead 1, 2, 3
• Assuming normal neurologic exam excludes stroke—75-80% of posterior circulation strokes have no focal deficits 1, 3
• Using CT instead of MRI when stroke is suspected—CT misses most posterior circulation infarcts 1, 3
• Performing HINTS if untrained—accuracy declines markedly without specific training 1, 3
• Ordering imaging for straightforward BPPV—unnecessary and delays treatment 4, 1
• Failing to assess fall risk in elderly patients with vestibular disorders 1, 3