What is the appropriate assessment and management of dizziness?

Assessment and Management of Dizziness

Initial Clinical Approach: Focus on Timing and Triggers

The most critical step in evaluating dizziness is to classify it by timing and triggers rather than relying on the patient's subjective description of "spinning" versus "lightheadedness," which is unreliable. 1

Categorize dizziness into one of four vestibular syndromes based on duration and precipitating factors 1, 2:

• Brief episodic vertigo (seconds to <1 minute): Triggered by head position changes → suggests BPPV (42% of all vertigo cases) 1
• Acute persistent vertigo (days to weeks): Constant symptoms → suggests vestibular neuritis (41% of peripheral vertigo) or posterior circulation stroke 1
• Spontaneous episodic vertigo (minutes to hours): No positional trigger → suggests vestibular migraine (14% of cases) or Ménière's disease 1
• Chronic vestibular syndrome (weeks to months): Persistent symptoms → consider medication side effects, anxiety/panic disorder, or posttraumatic vertigo 1

Essential History Elements

Obtain specific diagnostic details rather than vague descriptions 1:

• Duration of each episode: Seconds (BPPV), minutes-to-hours (vestibular migraine/Ménière's), days-to-weeks (vestibular neuritis/stroke) 1
• Triggers: Head position changes (BPPV), standing up (orthostatic hypotension), spontaneous (vestibular migraine) 1
• Associated auditory symptoms: Hearing loss, tinnitus, aural fullness → Ménière's disease (fluctuating) vs labyrinthitis (permanent profound loss) 1
• Migraine features: Headache, photophobia, phonophobia → vestibular migraine 1
• Vascular risk factors: Age >50, hypertension, diabetes, atrial fibrillation, prior stroke → increases stroke risk to 11-25% even with normal exam 1
• Medication review: Antihypertensives, sedatives, anticonvulsants, psychotropic drugs are the leading reversible cause of chronic dizziness 1

Physical Examination

Bedside Vestibular Testing

For brief episodic positional vertigo, perform the Dix-Hallpike maneuver bilaterally as the gold standard diagnostic test 1, 2:

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

For acute persistent vertigo, trained practitioners should perform the HINTS examination (Head-Impulse, Nystagmus, Test of Skew) 1:

• Peripheral features (reassuring): Abnormal head impulse test, unidirectional horizontal nystagmus, no skew deviation 1
• Central features (concerning): Normal head impulse test, direction-changing or vertical nystagmus, present skew deviation 1
• Critical caveat: HINTS has 100% sensitivity for stroke when performed by trained neuro-otology specialists but is unreliable when performed by emergency physicians or non-specialists 1

Neurologic Examination

• Observe for spontaneous nystagmus in all patients 2
• Complete neurologic exam to identify focal deficits 2
• Critical pitfall: 75-80% of patients with posterior circulation stroke have NO focal neurologic deficits, so normal exam does not exclude stroke 1

Orthostatic Vital Signs

• Check lying and standing blood pressure to assess for orthostatic hypotension 3, 4
• Standing up from supine position triggering symptoms suggests cardiovascular cause rather than vestibular disorder 1

Imaging Decisions

When Imaging Is NOT Indicated

No imaging is needed for 1, 2:

• Typical BPPV with positive Dix-Hallpike test and no red flags 1
• Acute persistent vertigo with normal neurologic exam AND peripheral HINTS pattern by trained examiner in low vascular risk patients 1
• Nonspecific dizziness without vertigo, ataxia, or neurologic deficits 1

When MRI Brain Without Contrast IS Indicated

Obtain urgent MRI (NOT CT) 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% have posterior circulation stroke) 1
• Abnormal neurologic examination 1
• HINTS examination suggesting central cause (by trained examiner) 1
• Unilateral or pulsatile tinnitus 1
• Asymmetric hearing loss 1
• Progressive neurologic symptoms 1

MRI has 4% diagnostic yield vs <1% for CT in isolated dizziness; CT misses most posterior circulation infarcts with only 10-20% sensitivity 1

Red Flags Requiring Immediate Imaging and Neurologic Consultation

1:

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

Treatment Based on Diagnosis

Benign Paroxysmal Positional Vertigo (BPPV)

Perform canalith repositioning procedures (Epley maneuver) immediately as first-line treatment 1, 2:

• 80% success rate after 1-3 treatments 1
• 90-98% success with repeat maneuvers if initial treatment fails 1
• No imaging or medication needed for typical cases 1
• Avoid vestibular suppressants (meclizine, dimenhydrinate, benzodiazepines) as they do not correct the mechanical pathology and delay central compensation 1

Counsel patients about 1:

• Recurrence risk: 10-18% at one year, up to 36% long-term 2
• Fall risk: Dizziness increases fall risk 12-fold in elderly patients 1
• Return promptly if symptoms recur for repeat repositioning 1

Vestibular Neuritis

• Vestibular suppressants limited to acute phase only 3
• Early vestibular rehabilitation to promote central compensation 1

Ménière's Disease

Diagnostic criteria require 1:

• At least two spontaneous vertigo episodes lasting 20 minutes to 12 hours
• Fluctuating low-to-mid frequency sensorineural hearing loss (documented by audiometry)
• Fluctuating tinnitus and aural fullness

Treatment 1, 3:

• Salt restriction and diuretics 3
• Intratympanic gentamicin for refractory vertigo 1
• Endolymphatic sac decompression surgery for patients failing medical therapy 1

Vestibular Migraine

Diagnostic criteria 1:

• Episodic vestibular symptoms (5 minutes to 72 hours)
• Migraine by International Headache Society criteria
• At least two migraine symptoms during at least two vertiginous episodes

Treatment: Migraine prophylaxis and lifestyle modifications 1

Persistent Dizziness After Initial Treatment

Refer for vestibular rehabilitation therapy when 1:

• Balance and motion tolerance do not improve despite initial treatment
• Particularly beneficial for elderly patients, those with CNS disorders, or heightened fall risk
• Significantly improves gait stability compared to medication alone 1

Common Diagnostic Pitfalls to Avoid

• Do not rely on patient descriptions of "spinning" vs "lightheadedness"—focus on timing and triggers instead 1
• Do not assume normal neurologic exam excludes stroke—75-80% of posterior circulation strokes have no focal deficits 1
• Do not use CT instead of MRI when stroke is suspected—CT misses most posterior circulation infarcts 1
• Do not rely on HINTS examination in emergency departments without expert examiners—obtain MRI for high-risk patients regardless 1
• Do not order routine imaging for isolated dizziness—diagnostic yield is <1% for CT and only 4% for MRI 1
• Do not overlook medication side effects—the most common reversible cause of chronic dizziness 1
• Do not miss vestibular migraine—accounts for 14% of vertigo cases but is extremely under-recognized, especially in young patients 1

Laboratory Testing

Laboratory testing has very low yield in dizziness 1:

• Check fingerstick glucose immediately—hypoglycemia is the most frequently identified unexpected abnormality 1
• Consider basic metabolic panel only if history or examination suggests specific abnormalities 1
• Avoid routine comprehensive laboratory panels—they rarely change management 1