How should I evaluate and treat an adult with new‑onset walking disequilibrium, possibly accompanied by dizziness, falls, or visual changes?

Evaluation and Management of Walking Disequilibrium

Begin with a focused temporal classification—acute (days), episodic (seconds to hours), or chronic (weeks to months)—because timing distinguishes benign peripheral causes from dangerous central pathology far more reliably than the patient's subjective description of "dizziness." 1, 2, 3

Initial Clinical Assessment

Critical History Elements

Duration of symptoms is the single most diagnostic feature:

• Seconds (<1 minute): BPPV is the primary consideration, affecting 9% of elderly patients undergoing geriatric assessment and causing a 12-fold increase in fall risk 4, 5, 1
• Minutes to hours: Vestibular migraine (14% of all vertigo cases) or Ménière's disease 1, 2
• Days to weeks: Vestibular neuritis (41% of peripheral vertigo) or posterior circulation stroke (25% of acute vestibular syndrome overall, rising to 75% in high-vascular-risk patients) 1, 2
• Weeks to months: Presbyvestibulopathy, medication side effects, or anxiety/panic disorder 5, 1, 2

Triggers must be systematically identified:

• Positional changes (head turning, lying down): BPPV 4, 1
• Standing from supine: Orthostatic hypotension, not vestibular pathology 1, 2
• Any head motion regardless of direction: Bilateral vestibular hypofunction 3

Associated symptoms narrow the differential:

• Hearing loss, tinnitus, aural fullness: Ménière's disease, vestibular schwannoma, or labyrinthitis 4, 1, 2
• Headache with photophobia/phonophobia: Vestibular migraine 1, 2
• Focal neurologic deficits, sudden hearing loss, inability to stand/walk, new severe headache: Posterior circulation stroke—requires immediate MRI 1, 2

Fall Risk Screening (Mandatory in All Elderly Patients)

Use the CDC three-question screen: 5

1. Have you fallen in the past year? How many times? Were you injured?
2. Do you feel unsteady when standing or walking?
3. Do you worry about falling?

BPPV patients have a 12-fold increased fall risk, and three-fourths of elderly BPPV patients had fallen within 3 months prior to diagnosis. 5, 1

Physical Examination

Positional Testing (First-Line Diagnostic Maneuver)

Perform the Dix-Hallpike maneuver bilaterally: 4, 1

• Bring patient from upright to supine with head turned 45° to one side, neck extended 20°
• Positive test: 5–20 second latency, then torsional upbeating nystagmus toward the affected ear, symptoms peak and resolve within 60 seconds 4, 1
• If negative bilaterally and history suggests BPPV: Perform supine roll test to assess lateral canal BPPV 4

HINTS Examination (For Acute Persistent Vertigo)

Only perform if trained; otherwise obtain MRI immediately in high-risk patients: 1, 2

• Head Impulse Test: Normal test (corrective saccade absent) suggests central cause
• Nystagmus: Direction-changing, vertical, or downbeating nystagmus indicates central pathology 4, 1
• Test of Skew: Vertical misalignment suggests central lesion 4

Critical caveat: HINTS has 100% sensitivity for stroke only when performed by trained neuro-otology specialists; emergency physicians achieve inadequate sensitivity. 1, 2

Neurologic Examination

Assess for posterior circulation stroke features: 4, 1

• Cranial nerve deficits (especially CN V, VII, VIII)
• Horner's syndrome
• Hemiparesis or sensory loss
• Cerebellar signs (ataxia, dysmetria, dysdiadochokinesia)
• Gait assessment—inability to stand or walk is a red flag 1, 2

Common pitfall: 75–80% of posterior circulation stroke patients with acute vestibular syndrome have NO focal neurologic deficits on examination. 1, 2

Diagnostic Testing Strategy

When Imaging Is NOT Indicated

Do not obtain imaging for: 4, 1, 2

• Typical BPPV with positive Dix-Hallpike and no red flags
• Acute persistent vertigo with normal neurologic exam, peripheral HINTS pattern (by expert examiner), and low vascular risk
• Nonspecific dizziness without vertigo, ataxia, or neurologic deficits

When MRI Brain Without Contrast IS Indicated

Obtain urgent MRI for: 1, 2

• 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)
• Abnormal neurologic examination
• HINTS examination suggesting central cause
• Focal neurologic deficits
• Sudden unilateral hearing loss
• Inability to stand or walk
• Downbeating or direction-changing nystagmus
• New severe headache with dizziness
• Unilateral or pulsatile tinnitus
• Asymmetric hearing loss
• Progressive neurologic symptoms

CT head has <1% diagnostic yield for isolated dizziness and misses most posterior circulation infarcts (sensitivity 10–20%); MRI has 4% yield and is essential for detecting posterior fossa strokes. 1, 2

Vestibular Testing

Do not order vestibular testing in patients who meet diagnostic criteria for BPPV without additional concerning features. 4

Consider comprehensive audiometry for: 1, 2

• Unilateral tinnitus
• Persistent symptoms despite treatment
• Suspected Ménière's disease (to document fluctuating low-to-mid frequency sensorineural hearing loss)

Medication Review (Essential in All Chronic Cases)

Medication side effects are a leading reversible cause of chronic disequilibrium: 1, 2, 6

• Antihypertensives (diuretics, β-blockers, calcium antagonists, ACE inhibitors)
• Sedatives and benzodiazepines
• Anticonvulsants
• Tricyclic antidepressants
• Antihistamines

Treatment Based on Diagnosis

BPPV (Most Common Cause)

Perform canalith repositioning procedure (Epley maneuver) immediately: 4, 5, 1

• 80% success rate after 1–3 treatments
• 90–98% success with repeat maneuvers if initial treatment fails
• Do not prescribe postprocedural postural restrictions 4
• Do not routinely treat with vestibular suppressant medications (antihistamines, benzodiazepines) 4

Reassess within 1 month to document resolution or persistence. 4

Vestibular Rehabilitation

Offer vestibular rehabilitation (self-administered or supervised) for: 4, 5, 1

• Persistent dizziness after initial BPPV treatment
• Presbyvestibulopathy in elderly patients
• Bilateral vestibular hypofunction
• Chronic vestibular syndrome not responding to initial management

Vestibular rehabilitation significantly improves gait stability compared to medication alone, particularly in elderly patients with CNS disorders or heightened fall risk. 5, 1

Presbyvestibulopathy (Age-Related Vestibular Decline)

Primary intervention is vestibular rehabilitation targeting: 5

• Gaze stabilization exercises
• Balance training
• Habituation exercises

Essential safety interventions: 5

• Avoid sudden head movements
• Use assistive devices as needed
• Ensure adequate home lighting
• Remove tripping hazards
• Assess for impaired mobility, CNS disorders, lack of home support

Red Flags Requiring Urgent Evaluation

Immediate MRI and neurologic consultation for: 1, 2

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

Common Diagnostic Pitfalls

Avoid these errors: 1, 2

• Relying on patient's description of "spinning" versus "lightheadedness"—focus on timing and triggers instead
• Assuming normal neurologic exam excludes stroke (75–80% of posterior circulation strokes have no focal deficits)
• Using CT instead of MRI when stroke is suspected (CT misses most posterior fossa infarcts)
• Performing HINTS examination without proper training and using results to exclude stroke
• Ordering routine imaging for isolated dizziness (very low yield, mostly incidental findings)
• Failing to screen for fall risk in elderly patients
• Overlooking medication side effects as a reversible cause

Interdisciplinary Referrals

Refer to neurology or otolaryngology for: 4, 5

• Skew deviation (vertical diplopia with head tilt suggesting brainstem/cerebellar pathology)
• Atypical presentations not responding to initial management
• Need for specialized vestibular testing
• Suspected central pathology

Refer to physical therapy, ophthalmology, cardiology as indicated based on modifying factors. 5