What is the appropriate work‑up for a patient who experiences brief (≈30‑second) episodes of dizziness triggered by looking up or down during routine activities, without chest pain, shortness of breath, or visual changes?

Work-Up for Brief Positional Dizziness

Your patient almost certainly has benign paroxysmal positional vertigo (BPPV), and the work-up consists of performing the Dix-Hallpike maneuver bilaterally—no imaging or laboratory testing is needed unless red-flag features are present. 1, 2

Immediate Bedside Diagnostic Testing

Perform the Dix-Hallpike maneuver on both sides to confirm posterior-canal BPPV, which accounts for 42% of all vertigo cases and is the most common cause of brief positional dizziness. 1, 3

Positive Dix-Hallpike Findings (Confirms BPPV)

• Latency of 5–20 seconds before symptoms and nystagmus begin 1, 4
• Torsional up-beating nystagmus toward the affected ear 1, 5
• Crescendo-decrescendo pattern with resolution within 60 seconds 1, 3
• Fatigability with repeated testing 1, 3

If Dix-Hallpike Is Negative

• Perform the supine roll test to evaluate for horizontal-canal BPPV, which accounts for 10–15% of BPPV cases 1, 2

When Imaging or Additional Testing Is NOT Indicated

Do not order neuroimaging, vestibular testing, or laboratory work when: 1, 2

• The Dix-Hallpike test is positive with typical nystagmus
• The neurological examination is normal
• No red-flag features are present (see below)
• The patient is under 50 years old without vascular risk factors

The diagnostic yield of CT in isolated positional dizziness is less than 1%, and routine imaging delays effective treatment. 1, 2

Red-Flag Features Requiring Urgent MRI Brain (Without Contrast)

Obtain immediate neuroimaging if any of the following are present: 1, 2

• Severe postural instability with falling (not just brief unsteadiness)
• New-onset severe headache accompanying the dizziness
• Any focal neurological deficits (dysarthria, limb weakness, diplopia, dysphagia, sensory loss, Horner's syndrome)
• Downbeating or purely vertical nystagmus without a torsional component
• Direction-changing nystagmus without head-position changes
• Baseline nystagmus present without provocative maneuvers
• Normal head-impulse test (suggests central cause)
• Sudden unilateral hearing loss
• Age >50 years with vascular risk factors (hypertension, diabetes, atrial fibrillation, prior stroke)—even with normal exam, 11–25% may have posterior-circulation stroke 1, 2

Immediate Treatment Upon Positive Diagnosis

Perform the Epley canalith repositioning maneuver immediately after confirming BPPV with a positive Dix-Hallpike test. 1, 4

• Success rate is 80% after 1–3 treatments 1, 5
• Success rises to 90–98% with repeat maneuvers if initial treatment fails 1, 4
• Do not prescribe vestibular suppressants (meclizine, dimenhydrinate, benzodiazepines) for BPPV—they do not correct the mechanical problem and delay central compensation 1, 4

Follow-Up Plan

• Reassess within 1 month to document resolution or persistence of symptoms 1, 2
• Repeat the Dix-Hallpike test if symptoms persist to confirm ongoing BPPV 1, 2
• Refer for vestibular rehabilitation therapy if vertigo persists after 2–3 repositioning attempts 1, 2

Common Pitfalls to Avoid

• Do not assume a normal neurologic exam excludes stroke—75–80% of posterior-circulation strokes present without focal deficits 1, 2
• Do not rely on patient descriptions of "spinning" versus "lightheadedness"—about 50% of BPPV patients describe their symptoms as vague dizziness or imbalance rather than classic rotational vertigo 1, 6
• Do not order CT when stroke is suspected—it misses most posterior-circulation infarcts and has <1% diagnostic yield for isolated dizziness 1, 2
• Do not order routine imaging for typical BPPV—it delays effective treatment and rarely changes management 1, 4