What is the initial assessment and management of a patient presenting with dizziness?

Initial Assessment and Management of Dizziness

Classify by Timing and Triggers—Not by Patient Description

Focus on timing and triggers rather than vague patient descriptors like "spinning" or "lightheadedness," as these subjective terms are unreliable and do not distinguish benign from dangerous causes. 1, 2, 3

The American Academy of Otolaryngology-Head and Neck Surgery and American College of Radiology emphasize that timing patterns guide your differential diagnosis and physical examination strategy far more effectively than asking patients to describe their sensation 1, 4, 2.

Four Key Timing Categories:

1. Brief Episodic (seconds to <1 minute):

• Triggered by head position changes → strongly suggests BPPV (accounts for 42% of all vertigo cases) 1, 3
• Perform Dix-Hallpike maneuver bilaterally immediately 1, 4, 2

2. Spontaneous Episodic (minutes to hours):

• With hearing loss, tinnitus, or aural fullness → Ménière's disease 1, 2, 5
• With headache, photophobia, phonophobia → vestibular migraine (14% of all vertigo, markedly under-recognized) 1, 2
• No hearing loss → consider vestibular migraine or TIA 1, 3

3. Acute Persistent (days to weeks):

• Continuous symptoms → vestibular neuritis (41% of peripheral vertigo) or posterior circulation stroke (25% of acute vestibular syndrome overall, rising to 75% in high-risk patients) 1, 3
• HINTS examination is critical here (see below) 1, 2

4. Chronic (weeks to months):

• Medication side effects are the leading reversible cause—review antihypertensives, sedatives, anticonvulsants, psychotropics 1, 2
• Screen for anxiety/panic disorder, posttraumatic vertigo 1

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Essential Physical Examination

For Brief Episodic Symptoms (Suspected BPPV):

Perform Dix-Hallpike maneuver bilaterally 1, 4, 2:

• Positive findings: 5–20 second latency, torsional upbeating nystagmus toward affected ear, symptoms resolve within 60 seconds 1, 2
• If negative, perform supine roll test to assess horizontal canal BPPV 1, 4
• 50% of BPPV patients describe "lightheadedness" or vague imbalance rather than classic spinning—do not skip positional testing based on symptom description alone 1

For Acute Persistent Symptoms (Suspected Stroke vs. Vestibular Neuritis):

HINTS examination (Head-Impulse, Nystagmus, Test of Skew) 1, 2:

• When performed by trained neuro-otology specialists: 100% sensitivity for stroke (outperforms early MRI at 46% sensitivity) 1
• Critical limitation: Emergency physicians and non-specialists do not achieve comparable accuracy—do not rely on HINTS alone in the ED 1

Central features (any one mandates urgent MRI):

• Normal head-impulse test 1, 2
• Direction-changing or vertical nystagmus 1, 2
• Skew deviation present 1, 2

Complete neurologic examination for focal deficits (dysarthria, limb weakness, diplopia, ataxia, dysmetria) 1, 2—but 75–80% of posterior circulation strokes have NO focal deficits, so normal exam does not exclude stroke 1

Orthostatic Vital Signs:

• Check for postural hypotension if symptoms occur with standing 1, 2

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Red Flags Requiring Urgent MRI Brain Without Contrast

Any of the following mandates immediate MRI 1, 2:

• Age >50 with vascular risk factors (hypertension, diabetes, atrial fibrillation, prior stroke)—even with normal neurologic exam, 11–25% harbor posterior circulation stroke 1, 2
• New severe headache accompanying dizziness 1, 2
• Focal neurologic deficits (dysarthria, limb weakness, diplopia, dysphagia, Horner's syndrome) 1, 2
• Sudden unilateral hearing loss 1, 2
• Inability to stand or walk 1, 2
• Downbeating or direction-changing nystagmus 1, 2
• HINTS examination suggesting central cause (by trained examiner) 1, 2
• Progressive neurologic symptoms 1, 2

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When Imaging Is NOT Indicated

Do not order imaging for 1, 4, 2:

• Typical BPPV with positive Dix-Hallpike, no red flags 1, 4, 2
• Acute persistent vertigo with normal neurologic exam, peripheral HINTS pattern (by trained examiner), low vascular risk 1, 2
• Nonspecific dizziness without vertigo, ataxia, or neurologic deficits 1, 2

CT head has <1% diagnostic yield for isolated dizziness and misses most posterior circulation infarcts (sensitivity 10–20%)—MRI with diffusion-weighted imaging is mandatory when stroke is suspected (4% diagnostic yield vs. <1% for CT) 1, 2

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Laboratory Testing

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

Check fingerstick glucose immediately—hypoglycemia is the most frequently identified unexpected abnormality 1

Selective testing only if history/exam suggests:

• Basic metabolic panel if vomiting, diarrhea, dehydration 2
• Thyroid function if affective symptoms 2

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Immediate Treatment Based on Diagnosis

BPPV (Positive Dix-Hallpike):

Perform Epley maneuver immediately 1, 4, 2:

• 80% success after 1–3 treatments; 90–98% with repeat maneuvers 1, 4, 2
• No imaging or medication needed for typical cases 1, 2
• Do not prescribe vestibular suppressants (meclizine, dimenhydrinate, benzodiazepines)—they delay central compensation and do not correct the mechanical pathology 1

Counsel patients:

• Recurrence risk: 10–18% at 1 year, up to 36% long-term 4
• Fall risk increases 12-fold, especially in elderly (BPPV present in 9% of elderly patients; three-fourths had fallen within prior 3 months) 1
• Reassess within 1 month 1

Vestibular Neuritis/Labyrinthitis:

• Short-course vestibular suppressants for severe acute symptoms only 2
• Early vestibular rehabilitation therapy to promote central compensation 1, 2

Ménière's Disease:

• Salt restriction, diuretics 1, 5
• Audiogram to document low-to-mid frequency sensorineural hearing loss 1
• Intratympanic dexamethasone or gentamicin for refractory cases 6

Vestibular Migraine:

• Migraine prophylaxis and lifestyle modifications 1, 2

Medication-Induced (Chronic Dizziness):

• Medication review is the most common reversible cause—adjust or discontinue offending agents 1, 2

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Common Pitfalls to Avoid

• Relying on patient descriptors ("spinning" vs. "lightheadedness") instead of timing and triggers 1, 2, 3
• Assuming normal neurologic exam excludes stroke—75–80% of posterior circulation strokes have no focal deficits 1
• Using CT instead of MRI when stroke is suspected—CT misses most posterior circulation infarcts 1, 2
• Relying on HINTS in the ED by non-experts—obtain MRI for high-risk patients regardless of HINTS results 1
• Ordering routine imaging for isolated dizziness—diagnostic yield <1% for CT, 4% for MRI 1, 2
• Failing to perform Dix-Hallpike in patients who describe "lightheadedness" rather than "spinning"—50% of BPPV patients use atypical descriptors 1
• Prescribing vestibular suppressants for BPPV—they are ineffective and delay recovery 1