How should I evaluate and manage a patient presenting with vertigo?

Approach to Vertigo

Classify vertigo by timing and triggers—not by patient descriptions of "spinning" versus "lightheadedness"—to rapidly distinguish benign peripheral causes from dangerous central pathology. 1, 2, 3

Initial Classification by Timing and Triggers

The American Academy of Otolaryngology-Head and Neck Surgery recommends categorizing dizziness into four distinct syndromes based on duration and triggers, as this approach is far more reliable than patient-reported symptom quality 1, 2, 3:

• Brief episodic vertigo (seconds to <1 minute): Triggered by specific head position changes → suggests BPPV 1, 2, 3
• Acute persistent vertigo (days to weeks): Constant symptoms → suggests vestibular neuritis, labyrinthitis, or posterior circulation stroke 1, 4, 2
• Spontaneous episodic vertigo (minutes to hours): No positional trigger → suggests vestibular migraine, Ménière's disease, or TIA 1, 2, 3
• Chronic vestibular syndrome (weeks to months): Persistent symptoms → suggests medication side effects, anxiety disorders, or posterior fossa mass 1

Critical History Elements

Duration of Episodes

• Seconds (<1 minute): BPPV 1, 2
• Minutes to hours: Vestibular migraine or Ménière's disease 1, 2
• Days to weeks: Vestibular neuritis or stroke 1, 2

Associated Symptoms

• Hearing loss, tinnitus, aural fullness: Ménière's disease or labyrinthitis 1, 4, 5
• Headache, photophobia, phonophobia: Vestibular migraine 1
• Focal neurologic symptoms (dysarthria, weakness, numbness, diplopia, dysphagia): Posterior circulation stroke 1, 6

Vascular Risk Factors

Document age >50, hypertension, diabetes, atrial fibrillation, or prior stroke—these patients have a 25% baseline risk of posterior circulation stroke with acute vestibular syndrome, rising to 75% in high-risk cohorts 1

Physical Examination

For Brief Episodic Vertigo (Suspected BPPV)

Perform the Dix-Hallpike maneuver bilaterally 1, 7, 4:

• Move patient from seated to supine, turn head 45° to one side, extend neck 20° backward 1
• Positive findings: 5–20 second latency, torsional upbeating nystagmus toward affected ear, symptoms resolve within 60 seconds, fatigability with repeat testing 1, 7
• If Dix-Hallpike negative: Perform supine roll test for lateral canal BPPV (10–15% of cases) 1

For Acute Persistent Vertigo (Suspected Stroke vs. Vestibular Neuritis)

Perform HINTS examination (Head-Impulse, Nystagmus, Test of Skew) 1, 7, 4:

CRITICAL CAVEAT: HINTS has 100% sensitivity for stroke only when performed by trained neuro-otology specialists; emergency physicians achieve inadequate sensitivity, so do NOT rely on HINTS alone in the ED—obtain urgent MRI for any high-risk patient regardless of HINTS results 1

• Peripheral pattern (vestibular neuritis): Abnormal head impulse test, unidirectional horizontal nystagmus, no skew deviation 1, 6
• Central pattern (stroke): Normal head impulse test, direction-changing or vertical nystagmus, skew deviation present 1, 6

Additional Examination Elements

• Orthostatic vital signs: Rule out postural hypotension 4, 5, 8
• Neurologic exam: Assess for dysarthria, limb weakness, sensory loss, ataxia, cranial nerve deficits 1, 6
• Assess nystagmus characteristics: Pure vertical nystagmus without torsional component, direction-changing nystagmus, or baseline nystagmus without provocation all indicate central pathology 1, 6

Red Flags Requiring Urgent MRI Brain Without Contrast

Any of the following mandate immediate neuroimaging 1:

• Age >50 with vascular risk factors (even if neurologic exam is normal—11–25% harbor posterior circulation stroke) 1
• Focal neurologic deficits (dysarthria, weakness, sensory loss, diplopia, dysphagia, Horner's syndrome) 1, 6
• Sudden unilateral hearing loss 1
• New severe headache accompanying vertigo 1
• Inability to stand or walk / severe postural instability with falling 1, 6
• Downbeating or pure vertical nystagmus without torsional component 1, 6
• Direction-changing nystagmus without head position changes 1, 6
• Baseline nystagmus present without provocative maneuvers 1, 6
• Normal head impulse test (suggests central cause) 1, 6
• Skew deviation on alternate cover testing 1, 6
• Failure to respond to appropriate vestibular treatments 1, 6

CRITICAL PITFALL: 75–80% of patients with posterior circulation stroke presenting with acute vestibular syndrome have NO focal neurologic deficits on exam—a normal neurologic exam does NOT exclude stroke 1

Imaging Decisions

When Imaging Is NOT Indicated

• Typical BPPV with positive Dix-Hallpike test and no red flags 1, 7
• Acute persistent vertigo with normal neurologic exam, peripheral HINTS pattern by trained examiner, and low vascular risk 1
• Nonspecific dizziness without vertigo, ataxia, or neurologic deficits 1

When Imaging IS Indicated

MRI brain without contrast (NOT CT) is first-line for 1:

• Any red flag features listed above 1
• High vascular risk patients with acute vestibular syndrome (even with normal exam) 1
• Unilateral or pulsatile tinnitus (add contrast to exclude vestibular schwannoma or vascular malformation) 1
• Asymmetric hearing loss 1

CT head has <1% diagnostic yield for isolated dizziness and misses most posterior circulation infarcts (sensitivity only 10–20%)—do NOT substitute CT for MRI when stroke is suspected 1

Treatment by Diagnosis

BPPV

Perform Epley maneuver (canalith repositioning) immediately upon diagnosis 1, 7, 4:

• 80% success after 1–3 treatments 1, 7
• 90–98% success with repeat maneuvers if initial treatment fails 1, 7
• Do NOT prescribe vestibular suppressants (meclizine, dimenhydrinate, benzodiazepines)—they delay central compensation and are ineffective for BPPV 1
• Reassess within 1 month to document resolution or persistence 1, 7

Vestibular Neuritis

• Supportive care with brief vestibular suppressants (≤3 days) for severe acute symptoms only 1, 4, 5
• Early vestibular rehabilitation therapy to promote central compensation 1, 4, 5

Ménière's Disease

• Salt restriction (<2 g/day) 1, 4, 5
• Diuretics (limited evidence) 1, 4, 5
• Intratympanic gentamicin or corticosteroids for refractory cases 1

Vestibular Migraine

• Migraine prophylaxis (beta-blockers, tricyclics, topiramate) 1
• Lifestyle modifications (sleep hygiene, trigger avoidance) 1
• Acute treatment with triptans or NSAIDs 1

Posterior Circulation Stroke

• Immediate neurology consultation and stroke protocol activation 1
• MRI with diffusion-weighted imaging 1

Common Pitfalls to Avoid

• Relying on patient descriptions of "spinning" versus "lightheadedness"—focus on timing and triggers instead 1, 2, 3
• Assuming normal neurologic exam excludes stroke—75–80% of posterior circulation strokes have no focal deficits 1
• Using HINTS in the ED without expert training—obtain MRI for high-risk patients regardless of HINTS results 1
• Ordering CT instead of MRI for suspected stroke—CT misses most posterior circulation infarcts 1
• Ordering routine imaging for isolated dizziness—diagnostic yield is <1% without red flags 1
• Prescribing vestibular suppressants for BPPV—they are ineffective and delay compensation 1
• Failing to perform Dix-Hallpike maneuver—it is the gold standard for diagnosing BPPV, the most common cause of vertigo 1, 7
• Overlooking medication side effects—antihypertensives, sedatives, anticonvulsants, and psychotropic drugs are leading reversible causes of chronic dizziness 1

Follow-Up

• Reassess within 1 month after initial treatment to document resolution or persistence 1, 7
• For persistent symptoms: Re-evaluate for concurrent vestibular disorders (35% of Ménière's patients also meet criteria for vestibular migraine), medication effects, psychiatric causes, or central pathology 1
• Counsel on fall risk: Dizziness increases fall risk 12-fold in elderly patients; BPPV is present in 9% of elderly patients, three-fourths of whom had fallen within 3 months 1