What are the possible etiologies and initial work‑up for dizziness in a 52‑year‑old adult?

Dizziness in a 52-Year-Old: Causes and Initial Work-Up

In a 52-year-old adult, dizziness most commonly stems from benign paroxysmal positional vertigo (BPPV), vestibular migraine, or medication side effects, but posterior circulation stroke must be actively excluded—especially when vascular risk factors are present—because it accounts for 25% of acute vestibular presentations overall and up to 75% in high-risk patients. 1, 2

Classification by Timing and Triggers (Not Symptom Quality)

Do not rely on the patient's description of "spinning" versus "lightheadedness"—instead, focus on episode duration and triggers to guide your differential diagnosis. 1, 3, 4

Brief Episodic Vertigo (Seconds to <1 Minute)

• Triggered by specific head position changes → strongly suggests BPPV, the most common cause of vertigo in adults (42% of all vertigo cases, 36.3% in older adults) 1, 2, 3
• No associated hearing loss, tinnitus, or aural fullness 1, 2
• Perform Dix-Hallpike maneuver bilaterally: look for 5–20 second latency, torsional upbeating nystagmus toward the affected ear, and symptom resolution within 60 seconds 1, 3

Spontaneous Episodic Vertigo (Minutes to Hours)

• Vestibular migraine (14% of all vertigo cases): episodes last 5 minutes to 72 hours with headache, photophobia, phonophobia, or visual aura; requires ≥5 episodes plus current or past migraine history 1, 2, 3
• Ménière's disease (10% of vertigo cases): episodes last 20 minutes to 12 hours with fluctuating low-to-mid frequency hearing loss, tinnitus, and aural fullness 1, 2, 3
• Transient ischemic attack: consider in patients >50 years with hypertension, diabetes, atrial fibrillation, or prior stroke 1, 4

Acute Persistent Vertigo (Days to Weeks)

• Vestibular neuritis (41% of peripheral vertigo): single prolonged episode of severe rotational vertigo lasting 12–36 hours, then 4–5 days of decreasing disequilibrium; no hearing loss 1, 2, 3
• Labyrinthitis: sudden severe vertigo >24 hours with profound, non-fluctuating hearing loss 1, 2
• Posterior circulation stroke: 75–80% of stroke patients with acute vestibular syndrome have NO focal neurologic deficits on initial exam, making stroke easy to miss 1, 2

Chronic Vestibular Syndrome (Weeks to Months)

• Medication side effects (leading reversible cause): review antihypertensives, sedatives, anticonvulsants, psychotropic drugs 1, 3, 5
• Anxiety/panic disorder: common cause of chronic dizziness; screen for psychiatric symptoms 1, 5
• Posttraumatic vertigo: history of head trauma with persistent vertigo, disequilibrium, tinnitus, headache 1, 2

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Critical Red Flags Requiring Urgent MRI Brain Without Contrast

Obtain MRI immediately (not CT) for any of the following—CT misses most posterior circulation infarcts with <1% diagnostic yield versus 4% for MRI: 6, 1

• Age >50 years with vascular risk factors (hypertension, diabetes, atrial fibrillation, prior stroke)—even with normal neurologic exam—because 11–25% harbor posterior circulation stroke 1, 2
• Abnormal HINTS examination (normal head-impulse test, direction-changing nystagmus, or skew deviation present) when performed by trained examiner 1, 3, 4
• Focal neurologic deficits: dysarthria, dysmetria, dysphagia, sensory/motor loss, Horner's syndrome 1, 2
• Sudden unilateral hearing loss 1, 3
• Inability to stand or walk 1
• Downbeating nystagmus or other central nystagmus patterns (direction-changing without head position change, gaze-evoked nystagmus) 1, 2
• New severe headache accompanying dizziness 6, 1
• Unilateral or pulsatile tinnitus 1
• Asymmetric hearing loss 1
• Progressive neurologic symptoms suggesting mass lesion 1

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Physical Examination Essentials

HINTS Examination (for Acute Persistent Vertigo)

When performed by trained neuro-otology specialists, HINTS has 100% sensitivity for stroke (versus 46% for early MRI)—but emergency physicians achieve inadequate accuracy, so do NOT rely on HINTS alone in the ED. 1, 3, 4

• Head-Impulse test: abnormal (corrective saccade) = peripheral; normal = central 1, 3
• Nystagmus: unidirectional horizontal = peripheral; direction-changing or vertical = central 1, 3
• Test of Skew: absent = peripheral; present = central 1, 3

Dix-Hallpike Maneuver (for Brief Episodic Vertigo)

• Perform bilaterally to diagnose posterior canal BPPV 1, 3
• Positive test: 5–20 second latency, torsional upbeating nystagmus, symptoms resolve within 60 seconds 1, 3

Additional Examination

• Orthostatic vital signs: measure blood pressure supine and after 3 minutes standing to detect orthostatic hypotension 3, 5
• Neurologic exam: assess for dysarthria, dysmetria, sensory/motor deficits, cranial nerve abnormalities 2, 3
• Cardiovascular exam: arrhythmias, murmurs 3, 5
• Otoscopic exam: assess for middle ear pathology 3

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Imaging Decisions

When Imaging Is NOT Indicated

• Typical BPPV with positive Dix-Hallpike test and no red flags 6, 1, 3
• Acute persistent vertigo with normal neurologic exam and HINTS consistent with peripheral vertigo (by trained examiner) in low vascular risk patient 6, 1
• Nonspecific dizziness without vertigo, ataxia, or neurologic deficits—CT yield <1%, MRI yield 4% 6, 1

When MRI Brain Without Contrast IS Indicated

• Any red flag listed above 6, 1
• High vascular risk patients (age >50, hypertension, diabetes, atrial fibrillation, prior stroke) with acute vestibular syndrome, even with normal exam 1, 2

When MRI Internal Auditory Canal With and Without Contrast IS Indicated

• Chronic recurrent vertigo with unilateral hearing loss or tinnitus to exclude vestibular schwannoma 1
• Suspected Ménière's disease requiring definitive diagnosis 1

CT Head: Avoid for Isolated Dizziness

• Diagnostic yield <1% for isolated dizziness 6, 1
• Sensitivity only 10–20% for posterior fossa strokes 1
• May be appropriate only as initial imaging in acute settings when MRI is unavailable and stroke is suspected 6, 1

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Laboratory Testing

Laboratory testing has very low yield in dizziness patients who have returned to baseline neurologic status. 1

• Fingerstick glucose immediately: hypoglycemia is the most frequently identified unexpected abnormality 1
• Basic metabolic panel: only if history or exam suggests specific abnormalities (dehydration, electrolyte disturbance) 1
• Avoid routine comprehensive laboratory panels: rarely change management 1

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Treatment Based on Diagnosis

BPPV (Most Common Cause)

• Canalith repositioning procedure (Epley maneuver) immediately: 80% success after 1–3 treatments, 90–98% with repeat maneuvers 1, 3, 5
• No imaging or medication needed for typical cases 1, 3
• Reassess within one month; counsel on recurrence risk and fall prevention 1

Vestibular Migraine

• Migraine prophylaxis (beta-blockers, tricyclic antidepressants, topiramate) and lifestyle modifications 1, 3
• Acute treatment: naproxen 500–550 mg + sumatriptan 50–100 mg orally when initiated promptly 1
• Avoid NSAIDs ≥15 days/month or triptans ≥10 days/month (medication-overuse headache risk) 1

Ménière's Disease

• Salt restriction and diuretics for persistent symptoms 1, 3, 5
• Oral corticosteroids for acute attacks 1
• Intratympanic gentamicin for refractory vertigo 1, 5
• Endolymphatic sac decompression surgery for patients failing medical therapy 1

Vestibular Neuritis

• Vestibular suppressants (antiemetics, benzodiazepines) limited to acute phase only 1, 5
• Early vestibular rehabilitation therapy to promote central compensation 1, 3, 5

Medication-Induced Dizziness

• Medication review and adjustment: leading reversible cause of chronic dizziness 1, 3, 5

Anxiety/Panic Disorder

• Psychiatric treatment and cognitive behavioral therapy 1, 5

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Common Pitfalls to Avoid

• Assuming normal neurologic exam excludes stroke: 75–80% of posterior circulation stroke patients with acute vestibular syndrome have no focal deficits 1, 2
• Relying on HINTS in the ED: non-experts achieve inadequate sensitivity; obtain MRI for high-risk patients regardless of HINTS results 1
• Using CT instead of MRI when stroke is suspected: CT misses most posterior circulation infarcts 6, 1
• Ordering routine imaging for isolated dizziness: very low yield and most findings are incidental 6, 1
• Failing to perform Dix-Hallpike maneuver: delays BPPV diagnosis and treatment 1, 3
• Overlooking medication side effects: common and reversible cause, especially in polypharmacy 1, 3, 5
• Missing vestibular migraine: extremely common (14% of vertigo cases) but under-recognized, particularly in young patients 1, 2

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Special Considerations for 52-Year-Olds

• Vascular risk assessment is critical: age >50 years alone increases stroke risk; document hypertension, diabetes, atrial fibrillation, smoking, hyperlipidemia, prior stroke 1, 2
• BPPV increases fall risk 12-fold: counsel on home safety, activity restrictions until resolved, and need for supervision if frail 1, 2
• Vestibular rehabilitation therapy is particularly beneficial for persistent dizziness, significantly improving gait stability compared to medication alone 1, 3, 5