How should I assess and manage a patient presenting with vertigo who has no red‑flag features such as focal neurological deficits, severe headache, fever, recent head trauma, sudden hearing loss, or signs of stroke?

Assessment and Management of Vertigo Without Red Flags

In a patient with vertigo and no red‑flag features, immediately perform the Dix‑Hallpike maneuver to diagnose benign paroxysmal positional vertigo (BPPV) and treat with the Epley repositioning maneuver if positive—no imaging or laboratory testing is required for typical BPPV. 1

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Initial Diagnostic Approach

Classify by Timing and Triggers

The most critical step is to categorize the vertigo by duration and triggers rather than relying on the patient's subjective description of "spinning" versus "lightheadedness," which is unreliable. 1

• Brief episodic vertigo (seconds to <1 minute) triggered by head‑position changes → strongly suggests BPPV (accounts for 42% of all vertigo cases). 1
• Acute persistent vertigo (days to weeks) with constant symptoms → suggests vestibular neuritis (41% of peripheral vertigo) or, less commonly, posterior circulation stroke. 1
• Spontaneous episodic vertigo (minutes to hours) → consider vestibular migraine (14% of all vertigo) or Ménière's disease. 1, 2

Key History Elements

• Associated auditory symptoms: Hearing loss, tinnitus, or aural fullness point toward Ménière's disease (fluctuating low‑to‑mid frequency hearing loss) rather than vestibular migraine (stable or absent hearing loss). 1, 2
• Migraine features: Headache, photophobia, phonophobia, or visual aura during vertigo episodes suggest vestibular migraine—this diagnosis is markedly under‑recognized, especially in younger patients. 1, 2
• Vascular risk factors: Age >50 years, hypertension, diabetes, atrial fibrillation, or prior stroke increase the likelihood of posterior circulation stroke even with a normal neurologic exam. 1
• Medication review: Antihypertensives, sedatives, anticonvulsants, and psychotropic drugs are leading reversible causes of chronic dizziness. 1

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Physical Examination

Dix‑Hallpike Maneuver (Gold Standard for BPPV)

Perform bilaterally in any patient with brief positional episodes, even if they do not describe classic "spinning." 1

Positive findings (diagnostic of posterior canal BPPV):

• Latency of 5–20 seconds before symptoms begin 1
• Torsional, upbeating nystagmus toward the affected ear 1
• Vertigo and nystagmus that increase then resolve within 60 seconds 1

If the Dix‑Hallpike is negative, perform the supine roll test to assess for horizontal canal BPPV (10–15% of BPPV cases). 1

HINTS Examination (for Acute Persistent Vertigo)

In patients with acute vestibular syndrome (continuous vertigo lasting days), the HINTS examination (Head Impulse, Nystagmus, Test of Skew) can distinguish peripheral from central causes—but only when performed by trained practitioners, where it achieves 100% sensitivity for stroke (versus 46% for early MRI). 1

Central features (require urgent MRI):

• Normal head impulse test (suggests central cause) 1
• Direction‑changing or vertical nystagmus 1
• Skew deviation on alternate cover testing 1

Critical pitfall: Emergency physicians and non‑specialists do not achieve comparable accuracy with HINTS; therefore, do not rely on HINTS alone in the emergency department—obtain urgent MRI for any high‑risk patient regardless of HINTS results. 1

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When Imaging Is NOT Indicated

• Typical BPPV with positive Dix‑Hallpike and no additional concerning features → no imaging needed. 1
• Acute persistent vertigo with normal neurologic exam, peripheral HINTS pattern (by trained examiner), and low vascular risk (age <50, no hypertension/diabetes/atrial fibrillation) → no imaging needed. 1
• Nonspecific dizziness without vertigo, ataxia, or neurologic deficits → imaging has extremely low yield (<1% for CT, ~4% for MRI). 1

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When Imaging IS Indicated

Urgent MRI Brain Without Contrast

Obtain immediately for any of the following red flags (even with normal neurologic exam in high‑risk patients):

• Age >50 years with vascular risk factors (hypertension, diabetes, atrial fibrillation, prior stroke)—11–25% may have posterior circulation stroke despite normal exam. 1
• New severe headache accompanying vertigo 1
• Focal neurologic deficits (dysarthria, limb weakness, diplopia, Horner's syndrome) 1
• Inability to stand or walk 1
• Downbeating or purely vertical nystagmus without torsional component 1
• Direction‑changing nystagmus that does not vary with head position 1
• Sudden unilateral hearing loss 1
• HINTS examination suggesting central cause (by trained examiner) 1

Why MRI, not CT? CT head has a diagnostic yield of <1% for isolated dizziness and misses most posterior circulation infarcts (sensitivity only 10–20%). MRI with diffusion‑weighted imaging is far superior (4% diagnostic yield). 1

MRI Brain and Internal Auditory Canal With and Without Contrast

For chronic recurrent vertigo with unilateral hearing loss or tinnitus to exclude vestibular schwannoma or confirm Ménière's disease. 1

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Treatment Based on Diagnosis

BPPV (Most Common Cause)

Epley canalith repositioning maneuver is first‑line treatment:

• 80% success after 1–3 treatments 1
• 90–98% success with repeat maneuvers if initial treatment fails 1
• No medications needed for typical BPPV 1

Avoid vestibular suppressants (meclizine, dimenhydrinate, benzodiazepines) for BPPV—they do not correct the mechanical pathology and may delay central compensation. 1 If used, limit to brief acute symptom relief only. 1

Follow‑up: Reassess within one month; counsel about recurrence risk (common), fall risk (12‑fold increase in elderly), and home safety. 1

Vestibular Neuritis

• Brief vestibular suppressants (antihistamines, benzodiazepines) for acute phase only 3
• Early vestibular rehabilitation therapy to promote central compensation 1, 4
• Avoid prolonged use of vestibular suppressants, as they impair compensation 3

Ménière's Disease

• Dietary sodium restriction to <1500–2000 mg/day 2
• Diuretics for persistent symptoms (limited evidence) 1
• Oral corticosteroids for acute attacks 1
• Intratympanic gentamicin for refractory vertigo 1
• Comprehensive audiometry to document fluctuating low‑to‑mid frequency sensorineural hearing loss 1, 2

Vestibular Migraine

• Migraine prophylaxis (beta‑blockers, calcium channel blockers, antiepileptics) 1, 2
• Lifestyle modifications: regular sleep, stress management, trigger avoidance 1, 2
• Discontinue betahistine if prescribed—it is ineffective for vestibular migraine 2

Diagnostic criteria (require all):

• ≥5 episodes lasting 5 minutes–72 hours 2
• Current or prior migraine history 2
• Migraine features in ≥50% of vertigo episodes 2

Labyrinthitis

• Sudden severe vertigo with profound hearing loss lasting >24 hours distinguishes labyrinthitis from vestibular neuritis (which has no hearing loss). 5
• Treatment is similar to vestibular neuritis: brief vestibular suppressants plus early vestibular rehabilitation. 3, 4

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Vestibular Rehabilitation Therapy

Primary intervention for persistent dizziness that fails initial treatment:

• Significantly improves gait stability compared to medication alone 1
• Particularly beneficial for elderly patients, those with CNS disorders, or heightened fall risk 1
• Includes habituation exercises, gaze stabilization, balance retraining, and fall prevention 1

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Common Diagnostic Pitfalls

• Assuming normal neurologic exam excludes stroke: 75–80% of patients with acute vestibular syndrome from posterior circulation infarct have no focal neurologic deficits. 1
• Relying on patient's description of "spinning" versus "lightheadedness"—focus on timing and triggers instead. 1
• Overlooking vestibular migraine: accounts for 14% of all vertigo but is markedly under‑recognized, especially in young patients. 1, 2
• Missing medication‑induced dizziness: antihypertensives, sedatives, anticonvulsants, and psychotropic drugs are leading reversible causes. 1
• Ordering routine imaging for isolated dizziness—has very low yield and most findings are incidental. 1
• Using CT instead of MRI when stroke is suspected—CT misses most posterior circulation infarcts. 1
• Failing to perform Dix‑Hallpike bilaterally: ~50% of BPPV patients describe symptoms as "lightheadedness" or "off‑balance" rather than classic spinning. 1

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Special Considerations for Elderly Patients

• BPPV is present in 9% of elderly patients referred for geriatric evaluation—three‑fourths had fallen within the prior 3 months. 1
• Dizziness increases fall risk 12‑fold in elderly patients. 1
• Age‑related physiological changes (reduced thirst, impaired sodium/water preservation, diminished baroreceptor response) increase vulnerability to dizziness and falls. 1
• Home safety assessment and supervision if elderly and frail are essential after BPPV diagnosis. 1

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Pharmacologic Symptom Control (After Excluding Life‑Threatening Causes)

• Meclizine is FDA‑approved for vertigo associated with vestibular system diseases in adults 6, but should be avoided for BPPV and used only briefly for acute vestibular neuritis or labyrinthitis. 1, 3
• Benzodiazepines are useful for acute vestibular neuritis and psychogenic vertigo (panic disorder, anxiety). 3
• Avoid prolonged vestibular suppressants—they impair central compensation and delay recovery. 1, 3