What is the appropriate assessment and initial management for a 62‑year‑old patient presenting with a new episode of vertigo?

Assessment and Management of Vertigo in a 62-Year-Old Patient

For a 62-year-old presenting with acute vertigo, immediately classify the syndrome by timing (seconds, minutes, hours, or days), perform the Dix-Hallpike maneuver bilaterally, and assess vascular risk factors—because this age group carries a 25% baseline risk of posterior circulation stroke when presenting with acute vestibular syndrome, rising to 75% in those with hypertension, diabetes, or atrial fibrillation. 1

Initial Classification by Timing and Triggers

Focus on objective timing rather than the patient's subjective description of "dizziness" or "spinning"—these terms are unreliable for diagnosis. 1

• Brief episodic vertigo (seconds to <1 minute) triggered by head position changes suggests BPPV, which accounts for 42% of all vertigo cases 1, 2
• Spontaneous episodic vertigo (minutes to hours) without positional triggers suggests vestibular migraine (14% of cases) or Ménière's disease 1, 2
• Acute persistent vertigo (days to weeks) with continuous symptoms suggests vestibular neuritis (41% of peripheral vertigo), labyrinthitis, or posterior circulation stroke 1, 2
• Chronic vertigo (weeks to months) suggests medication side effects (the most common reversible cause), anxiety disorders, or posterior fossa mass 1

Critical Red Flags Requiring Urgent MRI

Do NOT assume a normal neurologic exam excludes stroke—75-80% of posterior circulation strokes presenting with acute vestibular syndrome have no focal neurologic deficits. 1, 3

Obtain urgent MRI brain without contrast (NOT CT, which has <1% diagnostic yield and misses most posterior circulation infarcts) if ANY of the following are present: 4, 1

• Age >50 with vascular risk factors (hypertension, diabetes, atrial fibrillation, prior stroke)—even with normal neurologic exam 1
• New severe headache accompanying vertigo 1
• Severe postural instability with falling 1, 3
• Focal neurologic deficits (dysarthria, limb weakness, diplopia, dysphagia, Horner's syndrome) 1, 3
• Pure vertical nystagmus (up-beating or down-beating) without torsional component 1, 3
• Direction-changing nystagmus without head position changes 1, 3
• Baseline nystagmus present without provocative maneuvers 1, 3
• Normal head-impulse test (suggests central cause) 1
• Skew deviation on alternate cover testing 1
• Sudden unilateral hearing loss 1

Physical Examination Algorithm

Step 1: Perform Dix-Hallpike Maneuver Bilaterally

Execute this maneuver on EVERY patient with positional symptoms—it has 82% sensitivity and 71% specificity for posterior canal BPPV. 2

Technique: Move patient from seated to supine, turn head 45° to the side being tested, extend neck ≈20° 1, 2

Positive peripheral (BPPV) findings: 1, 2

• Latency period of 5-20 seconds before symptoms begin
• Torsional, up-beating nystagmus toward the affected ear
• Vertigo and nystagmus increase then resolve within 60 seconds
• Fatigability with repeated testing

Red-flag central findings requiring immediate MRI: 1, 3

• Immediate onset without latency
• Persistent nystagmus beyond 60 seconds
• Purely vertical nystagmus without torsional component
• Down-beating nystagmus
• No fatigability with repeat testing

Step 2: If Dix-Hallpike Negative, Perform Supine Roll Test

This detects lateral canal BPPV, which accounts for 10-15% of BPPV cases and is frequently missed. 1, 2

Technique: With patient supine, rapidly turn head 90° to each side 1, 2

Positive finding: Horizontal nystagmus (geotropic most common, or apogeotropic) with vertigo 1, 2

Step 3: HINTS Examination (Only if Trained)

The HINTS exam (Head Impulse, Nystagmus, Test of Skew) has 100% sensitivity for stroke when performed by trained neuro-otology specialists, but is unreliable when performed by non-experts—therefore, do NOT rely on HINTS alone in the emergency department; obtain MRI for any high-risk patient regardless of HINTS results. 1

Treatment Based on Diagnosis

For Confirmed BPPV (Positive Dix-Hallpike, No Red Flags)

Perform the Epley canalith repositioning maneuver immediately—do NOT prescribe meclizine or other vestibular suppressants, as they prevent central compensation and delay recovery. 1, 2, 5

• Success rate: 80% after 1-3 treatments; 90-98% with additional maneuvers if initial treatment fails 1, 2
• No imaging needed for typical BPPV with positive Dix-Hallpike and no red flags 4, 1, 2
• Reassess within 1 month to document resolution or identify treatment failures 1, 2
• Counsel on fall risk: BPPV increases fall risk 12-fold in elderly patients; 9% of elderly patients with BPPV have fallen in the prior 3 months 1

For Acute Vestibular Syndrome (Days of Continuous Vertigo)

If patient is >50 years old with ANY vascular risk factors, obtain urgent MRI even with normal neurologic exam—11-25% will have posterior circulation stroke. 1

If low vascular risk AND trained examiner performs HINTS showing peripheral features AND normal neurologic exam: No imaging needed, treat as vestibular neuritis 1

For Suspected Ménière's Disease

Diagnostic criteria: At least two episodes of vertigo lasting 20 minutes to 12 hours, fluctuating low-to-mid frequency sensorineural hearing loss, tinnitus or aural fullness 1

• Obtain comprehensive audiometry to document fluctuating hearing loss 1
• Treatment: Salt restriction, diuretics, intratympanic gentamicin for refractory cases 1

For Suspected Vestibular Migraine

Diagnostic criteria: Episodic vestibular symptoms with migraine features (headache, photophobia, phonophobia) during at least two episodes, stable or absent hearing loss (NOT fluctuating like Ménière's) 1, 3

• Treatment: Migraine prophylaxis and lifestyle modifications 1
• Common pitfall: Vestibular migraine accounts for 14% of all vertigo cases but is markedly under-recognized, especially in younger adults 1

When NOT to Order Imaging

Avoid routine CT or MRI for: 4, 1, 2

• Typical BPPV with positive Dix-Hallpike and no red flags (diagnostic yield <1%)
• Acute persistent vertigo with normal neurologic exam, low vascular risk, and peripheral HINTS pattern by trained examiner
• Nonspecific dizziness without vertigo, ataxia, or neurologic deficits

Medication Review

Systematically review antihypertensives, sedatives, anticonvulsants, and psychotropic agents—medication side effects are the most common reversible cause of chronic vestibular symptoms. 1

Common Pitfalls to Avoid

• Relying on patient description of "spinning" vs "lightheadedness" instead of focusing on timing and triggers 1
• Assuming normal neurologic exam excludes stroke (75-80% of posterior circulation strokes have no focal deficits) 1
• Ordering CT instead of MRI when stroke is suspected (CT misses most posterior circulation infarcts) 4, 1
• Prescribing meclizine for BPPV (delays central compensation; repositioning maneuvers are first-line) 1, 5
• Failing to perform supine roll test after negative Dix-Hallpike (misses 10-15% of BPPV cases) 1, 2
• Overlooking vestibular migraine in patients with both migraine history and vertigo (accounts for 14% of cases) 1