What is the appropriate work‑up for a patient presenting with vertigo?

Work-Up of Vertigo

The work-up of vertigo should be driven by timing and triggers rather than the patient's subjective description of "dizziness" or "spinning," with the primary goal of distinguishing benign peripheral causes from dangerous central pathology—particularly posterior circulation stroke. 1

Initial History: Classify by Timing Pattern

Focus on duration and triggers to categorize into one of four vestibular syndromes 1, 2, 3:

1. Triggered Episodic Vestibular Syndrome (seconds to <1 minute)

• Episodes provoked by specific head position changes relative to gravity (rolling over in bed, looking up, bending forward) 4, 1
• Most commonly BPPV (42% of all vertigo cases) 1, 5
• No hearing loss, tinnitus, or aural fullness 4, 1

2. Acute Vestibular Syndrome (days to weeks of continuous symptoms)

• Constant vertigo with nausea, vomiting, and intolerance to head motion 1, 2
• Differential: vestibular neuritis (41% of peripheral vertigo), labyrinthitis, or posterior circulation stroke (25% overall, 75% in high-risk vascular patients) 1, 5
• Critical: 75-80% of posterior circulation strokes present WITHOUT focal neurologic deficits 1, 6

3. Spontaneous Episodic Vestibular Syndrome (minutes to hours)

• Episodes occur without positional triggers 1, 2
• Differential: vestibular migraine (14% of vertigo), Ménière's disease, or vertebrobasilar TIA 1, 5
• Fluctuating hearing loss, tinnitus, and aural fullness suggest Ménière's 1, 5
• Headache with photophobia/phonophobia suggests vestibular migraine 1, 5

4. Chronic Vestibular Syndrome (weeks to months)

• Differential: medication side effects (leading reversible cause), anxiety/panic disorder, posttraumatic vertigo, posterior fossa mass 1, 5

Critical Red Flags Requiring Urgent MRI Brain Without Contrast

Any of the following mandate immediate neuroimaging 1, 6:

• Age >50 years with vascular risk factors (hypertension, diabetes, atrial fibrillation, prior stroke)—even with normal neurologic exam, 11-25% harbor posterior circulation stroke 1, 6
• New severe headache accompanying vertigo 1, 6
• Focal neurologic deficits: dysarthria, limb weakness, sensory loss, diplopia, dysphagia, Horner's syndrome 1, 5, 6
• Inability to stand or walk independently 1, 6
• Sudden unilateral hearing loss 1, 6
• Downbeating or pure vertical nystagmus without torsional component 1, 5, 6
• Direction-changing nystagmus without head position changes 1, 5
• Baseline nystagmus present without provocative maneuvers 1, 5, 6
• Abnormal HINTS examination (see below) suggesting central cause 1, 6
• Failure to respond to appropriate peripheral vertigo treatments 1, 6

Physical Examination Protocol

For Triggered Episodic Symptoms (Suspected BPPV)

Perform Dix-Hallpike maneuver bilaterally 4, 1:

1. Turn patient's head 45° to one side
2. Move from seated to supine position with head extended 20° backward
3. Positive findings (posterior canal BPPV):
   • Latency of 5-20 seconds before symptom onset 4, 1
   • Torsional, upbeating nystagmus toward affected ear 4, 1
   • Symptoms increase then resolve within 60 seconds 4, 1
   • Fatigues with repeated testing 4, 5

If Dix-Hallpike negative, perform supine roll test for horizontal canal BPPV (10-15% of BPPV cases) 1, 5:

• Rapidly turn head 90° to each side while supine
• Positive: horizontal nystagmus with vertigo 1

For Acute Vestibular Syndrome (Continuous Vertigo)

HINTS examination (Head-Impulse, Nystagmus, Test of Skew)—only reliable when performed by trained practitioners 1, 6:

Central features (stroke) 1, 5:

• Normal head impulse test (no corrective saccade)
• Direction-changing or pure vertical nystagmus
• Skew deviation on alternate cover test

Peripheral features (vestibular neuritis) 1, 5:

• Abnormal head impulse test (corrective saccade present)
• Unidirectional horizontal nystagmus
• No skew deviation

Critical pitfall: Emergency physicians achieve inadequate sensitivity with HINTS; obtain MRI for high-risk patients regardless of HINTS results 1, 6

Additional Examination Elements

• Orthostatic vital signs to assess for postural hypotension 7, 8
• Comprehensive neurologic exam for focal deficits 6, 7
• Otoscopic exam and hearing assessment 1
• Gait testing: severe postural instability with falling is a red flag for central pathology 1, 6

Diagnostic Testing

When Imaging Is NOT Indicated

• Typical BPPV with positive Dix-Hallpike, no red flags 1, 6
• Acute persistent vertigo in patient <50 years, no vascular risk factors, normal neurologic exam, peripheral HINTS pattern by trained examiner 1, 6
• Nonspecific dizziness without vertigo, ataxia, or neurologic deficits 1, 6

When Imaging IS Indicated

MRI brain without contrast (preferred modality) 1, 6:

• Any red flag features listed above
• CT head has <1% diagnostic yield for isolated dizziness and misses most posterior circulation infarcts (sensitivity 10-40%) 1, 6
• MRI has 4% diagnostic yield and is essential for detecting posterior circulation strokes 1, 6

MRI brain and internal auditory canal with and without contrast 1:

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

Laboratory Testing

Generally NOT helpful in isolated vertigo 7, 8:

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

Audiometry

Obtain comprehensive audiologic examination for 1:

• Unilateral tinnitus
• Persistent symptoms
• Associated hearing difficulties
• Suspected Ménière's disease (documents fluctuating low-to-mid frequency sensorineural hearing loss)

Treatment Based on Diagnosis

BPPV (Positive Dix-Hallpike)

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

• 80% success after 1-3 treatments 1, 5
• 90-98% success with repeat maneuvers if initial treatment fails 1, 5
• Do NOT prescribe vestibular suppressants (meclizine, dimenhydrinate, benzodiazepines)—they delay central compensation 1, 5
• Reassess within 1 month to document resolution 1, 5

Vestibular Neuritis (Peripheral Acute Vestibular Syndrome)

• Vestibular suppressants limited to acute phase only 7, 8
• Early vestibular rehabilitation therapy to promote central compensation 1, 7

Ménière's Disease

• Salt restriction and diuretics 1, 7, 8
• Intratympanic gentamicin or dexamethasone for refractory cases 1, 8

Vestibular Migraine

• Migraine prophylaxis and lifestyle modifications 1, 5
• Acute treatment with NSAIDs and triptans when appropriate 1

Persistent Dizziness After Initial Treatment

Refer for vestibular rehabilitation therapy 1, 5:

• Significantly improves gait stability compared to medication alone
• Particularly beneficial for elderly patients or those with heightened fall risk

Common Diagnostic Pitfalls to Avoid

• Do NOT rely on patient's description of "spinning" vs "lightheadedness"—focus on timing and triggers 1, 6
• Do NOT assume normal neurologic exam excludes stroke—75-80% of posterior circulation strokes lack focal deficits 1, 6
• Do NOT use CT instead of MRI when stroke is suspected—CT misses most posterior circulation infarcts 1, 6
• Do NOT order routine imaging for isolated dizziness with typical peripheral features—diagnostic yield <1% 1, 6
• Do NOT overlook medication review—medication side effects are the leading reversible cause of chronic dizziness 1, 5
• Do NOT miss vestibular migraine—extremely common (14% of vertigo) but markedly under-recognized 1, 5