What is the appropriate evaluation and management for a patient presenting with dizziness?

Evaluation and Management of Dizziness

Focus your evaluation on timing, triggers, and associated symptoms rather than the patient's subjective description of "dizziness," then perform targeted bedside maneuvers to distinguish benign peripheral causes from dangerous central pathology—most patients do not require imaging. 1, 2

Initial Clinical Assessment

Critical History Elements

Determine the temporal pattern first:

• Seconds to <1 minute triggered by head position changes → BPPV (most common, 42% of all vertigo) 1, 3
• Minutes to hours, spontaneous episodes → Vestibular migraine (14% of cases) or Ménière's disease 1, 3
• Days to weeks, continuous symptoms → Vestibular neuritis (41% of peripheral vertigo) or posterior circulation stroke 1, 3

Identify specific triggers:

• Head position changes strongly suggest BPPV 1, 2
• Standing from supine suggests orthostatic hypotension (cardiovascular, not vestibular) 1
• No trigger with spontaneous onset suggests vestibular neuritis or stroke 2

Screen for associated symptoms:

• Hearing loss, tinnitus, or aural fullness → Ménière's disease or labyrinthitis 1, 3, 2
• Headache with photophobia/phonophobia → Vestibular migraine 1, 2
• Focal neurologic symptoms (diplopia, dysarthria, numbness, weakness) → Central cause requiring urgent imaging 2

Assess Vascular Risk Factors

Age >50 years plus any of the following dramatically increases stroke risk:

• Hypertension, diabetes, atrial fibrillation, or prior stroke 1, 2
• In high-risk cohorts, posterior circulation stroke accounts for 75% of acute vestibular syndrome cases (vs. 25% overall) 1

Physical Examination

Essential Bedside Maneuvers

For brief episodic symptoms (<1 minute):

• Perform the Dix-Hallpike maneuver bilaterally as the gold standard for BPPV 1, 3, 2
• Positive findings: 5-20 second latency, torsional upbeating nystagmus toward affected ear, symptoms resolve within 60 seconds 1, 3, 2
• If negative, perform supine roll test for horizontal canal BPPV 1

For acute persistent symptoms (days to weeks):

• Complete neurologic examination checking for focal deficits, ataxia, dysmetria 2
• HINTS examination (Head Impulse, Nystagmus, Test of Skew) if trained: 100% sensitivity for stroke when performed by specialists 1, 3
• Critical caveat: HINTS is unreliable when performed by non-experts; do not rely on it alone in emergency settings—obtain MRI for high-risk patients regardless 1

Additional examination:

• Orthostatic vital signs (standing from supine suggests cardiovascular cause) 1, 2
• Assess for nystagmus patterns: direction-changing or vertical nystagmus suggests central pathology 1

Laboratory Testing

Routine labs are NOT indicated for isolated dizziness with normal vital signs. 2

Selective testing only when history/exam suggests:

• Fingerstick glucose immediately (hypoglycemia is the most common unexpected abnormality) 1
• Basic metabolic panel only if vomiting, diarrhea, or dehydration present 2
• Comprehensive panels rarely change management 1

Imaging Decisions

When Imaging Is NOT Needed

Do not order imaging for: 1, 2

• Brief episodic vertigo with positive Dix-Hallpike and typical BPPV features
• Acute persistent vertigo with normal neurologic exam and peripheral HINTS findings (by trained examiner) in low vascular risk patients
• Chronic nonspecific dizziness without focal neurologic signs

When MRI Brain Without Contrast IS Required

Obtain urgent MRI for any of these red flags: 1, 2

• Focal neurologic deficits on examination
• Abnormal HINTS examination (normal head impulse, direction-changing nystagmus, skew deviation)
• New severe headache accompanying dizziness
• Inability to stand or walk
• Downbeating or direction-changing nystagmus
• Sudden unilateral hearing loss
• Progressive neurologic symptoms
• High vascular risk (age >50 + hypertension/diabetes/AF/prior stroke) EVEN with normal neurologic exam (11-25% harbor posterior circulation stroke) 1

MRI with and without contrast for:

• Unilateral or pulsatile tinnitus (exclude vestibular schwannoma or vascular malformation) 1, 3
• Asymmetric hearing loss 1, 2

Critical Imaging Pitfalls to Avoid

• CT head has <1% diagnostic yield for isolated dizziness and misses most posterior circulation infarcts (sensitivity only 10-20%) 1
• Do not substitute CT for MRI when stroke is suspected—MRI has 4% diagnostic yield vs. <1% for CT 1
• 75-80% of posterior circulation stroke patients have NO focal neurologic deficits on standard examination—normal exam does not exclude stroke 1, 3

Management by Diagnosis

BPPV (Most Common)

Immediate treatment with canalith repositioning:

• Perform Epley maneuver immediately after positive Dix-Hallpike 1, 2
• 80% success after 1-3 treatments; 90-98% with repeat maneuvers 1, 2
• No imaging or medication needed for typical cases 1
• Reassess within one month; counsel on recurrence risk and fall prevention 1

Avoid vestibular suppressants (meclizine, dimenhydrinate, benzodiazepines)—they do not correct the mechanical problem and delay central compensation 1

Vestibular Neuritis/Labyrinthitis

• Supportive care and vestibular rehabilitation therapy 2
• Short-course vestibular suppressants only for severe acute symptoms 2
• Early mobilization promotes central compensation 1

Ménière's Disease

• Salt restriction and diuretics 1
• Intratympanic gentamicin or dexamethasone for refractory cases 1
• Audiometry to document fluctuating low-to-mid frequency sensorineural hearing loss 1

Vestibular Migraine

• Migraine prophylaxis and lifestyle modifications 1, 2
• Distinguish from Ménière's by absence of fluctuating hearing loss 1
• Extremely common (14% of vertigo) but under-recognized, especially in young patients 1

Medication-Induced Dizziness

Review and adjust medications—a leading reversible cause: 1

• Antihypertensives, sedatives, anticonvulsants, psychotropic drugs
• Particularly important in elderly patients with chronic vestibular syndrome 1

Vestibular Rehabilitation Therapy

Refer when symptoms persist after initial treatment:

• Significantly improves gait stability compared to medication alone 1, 2
• Particularly beneficial for elderly patients or those with heightened fall risk 1
• Includes habituation exercises, gaze stabilization, balance retraining 1

Special Considerations for Elderly Patients

• Dizziness increases fall risk 12-fold 1
• BPPV present in 9% of elderly patients referred for geriatric evaluation; three-fourths had fallen within prior 3 months 1
• Document fall history, circumstances, and injuries 1
• Age-related physiological changes increase vulnerability (reduced baroreceptor response, impaired sodium/water preservation) 1

Common Diagnostic Pitfalls

• Do not rely on patient descriptions of "spinning" vs. "lightheadedness"—focus on timing and triggers instead 1, 3, 2
• Vestibular migraine is extremely under-recognized, particularly in young patients—always ask about migraine history 1
• Panic disorder can cause both lightheadedness AND true vestibular dysfunction—screen for psychiatric symptoms 1
• Routine imaging has very low yield and most findings are incidental 1