What is the recommended work‑up for a patient presenting with dizziness?

Medical Advisory BoardAll articles are reviewed for accuracy by our Medical Advisory Board
Educational purpose only • Exercise caution as content is pending human review
Article Review Status
Submitted
Under Review
Approved

Last updated: February 24, 2026 • View editorial policy

Personalize

Help us tailor your experience

Which best describes you? Your choice helps us use language that's most understandable for you.

Work-Up for Dizziness

Categorize dizziness by timing and triggers—not by the patient's subjective description—to determine the specific vestibular syndrome, then perform targeted bedside maneuvers and reserve imaging for high-risk features only. 1, 2

Step 1: Classify by Timing and Triggers

Avoid relying on patient descriptors such as "spinning," "lightheadedness," or "off-balance"—these terms are unreliable and do not distinguish benign from dangerous causes. 1, 3 Instead, focus on:

Duration and Pattern

  • Seconds to <1 minute (triggered by head position changes) → Benign Paroxysmal Positional Vertigo (BPPV), the most common cause (42% of all vertigo). 1, 2
  • Minutes to hours (spontaneous episodes) → Vestibular migraine (14% of cases, often under-recognized) or Ménière's disease. 1, 2
  • Days to weeks (acute persistent, constant symptoms) → Acute Vestibular Syndrome (AVS): vestibular neuritis (41% of peripheral vertigo) or posterior circulation stroke (25% overall, rising to 75% in high-risk patients). 1, 2
  • Weeks to months (chronic) → Medication side effects (the leading reversible cause), anxiety/panic disorder, posttraumatic vertigo, or posterior fossa mass. 2, 3

Triggers

  • Positional changes (rolling over in bed, looking up) → BPPV. 1, 2
  • Standing from supine → Orthostatic hypotension (cardiovascular, not vestibular). 2, 3
  • Spontaneous (no trigger) → Vestibular migraine, Ménière's, or stroke. 1, 2

Step 2: Obtain Targeted History

Associated Symptoms

  • Hearing loss, tinnitus, aural fullness → Ménière's disease (fluctuating hearing loss) or vestibular schwannoma (progressive unilateral hearing loss). 1, 2
  • Headache, photophobia, phonophobia → Vestibular migraine. 1, 2
  • Focal neurologic symptoms (dysarthria, diplopia, dysphagia, limb weakness, numbness) → Posterior circulation stroke. 1, 2

Vascular Risk Factors

  • Age >50 years, hypertension, diabetes, atrial fibrillation, prior stroke → High risk for posterior circulation stroke (11–25% even with normal neurologic exam). 1, 2

Medication Review

  • Antihypertensives, sedatives, anticonvulsants, psychotropic drugs → Leading reversible cause of chronic dizziness. 2, 3

Step 3: Perform Targeted Physical Examination

For All Patients

  • Observe for spontaneous nystagmus at rest (direction-changing, vertical, or persistent baseline nystagmus suggests central cause). 1, 2
  • Complete neurologic examination: cranial nerves, cerebellar testing (finger-to-nose, heel-to-shin), gait assessment, and Romberg test. 1, 2
  • Orthostatic vital signs (if standing triggers symptoms). 2, 4

For Triggered Episodic Symptoms (Seconds, Positional)

  • Dix-Hallpike maneuver bilaterally for posterior canal BPPV: positive if 5–20 second latency, torsional upbeating nystagmus toward the affected ear, symptoms resolve within 60 seconds. 1, 2
  • Supine roll test if Dix-Hallpike is negative (to detect horizontal canal BPPV, 10–15% of cases). 1, 2

For Acute Vestibular Syndrome (Days to Weeks, Constant)

  • HINTS examination (Head-Impulse, Nystagmus, Test of Skew)—only if you are trained—has 100% sensitivity for stroke when performed by experts, superior to early MRI (46% sensitivity). 1, 2
    • Central features (stroke): normal head impulse test, direction-changing or vertical nystagmus, skew deviation present. 1, 2
    • Peripheral features (vestibular neuritis): abnormal head impulse test, unidirectional horizontal nystagmus, no skew deviation. 1, 2
  • Critical pitfall: 75–80% of posterior circulation strokes have no focal neurologic deficits, so a normal neurologic exam does not exclude stroke. 1, 2
  • Do not rely on HINTS in the emergency department if not trained—obtain MRI for high-risk patients regardless. 1, 2

Step 4: Decide on Imaging

No Imaging Indicated

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

MRI Brain Without Contrast (First-Line)

Obtain urgently for any of the following red flags:

  • Age >50 years with vascular risk factors (hypertension, diabetes, atrial fibrillation, prior stroke), even if neurologic exam is normal. 1, 2
  • Abnormal neurologic examination (dysarthria, limb weakness, diplopia, Horner's syndrome). 1, 2
  • HINTS examination suggesting central cause (normal head impulse, direction-changing nystagmus, skew deviation). 1, 2
  • New severe headache accompanying dizziness. 1, 2
  • Sudden unilateral hearing loss. 1, 2
  • Inability to stand or walk. 1, 2
  • Downbeating or other central nystagmus patterns (vertical, direction-changing, persistent baseline). 1, 2
  • Unilateral or pulsatile tinnitus (to exclude vestibular schwannoma or vascular malformation). 1, 2
  • Asymmetric hearing loss. 1, 2

Why MRI, not CT? CT has <1% diagnostic yield for isolated dizziness and only 10–20% sensitivity for posterior circulation infarcts, whereas MRI with diffusion-weighted imaging has ~4% yield and is far superior for detecting stroke. 1, 2

MRI Head and Internal Auditory Canal With and Without Contrast

  • Chronic recurrent vertigo with unilateral hearing loss or tinnitus (to exclude vestibular schwannoma or confirm Ménière's disease). 2, 3

CT Head Without Contrast

  • Only if MRI is unavailable in the acute setting when stroke is suspected, but recognize its poor sensitivity (10–20%) for posterior fossa strokes. 1, 2

CTA Head and Neck

  • Pulsatile tinnitus (to evaluate for vascular malformations, arterial dissection, sigmoid sinus abnormalities). 2, 3
  • Suspected vertebrobasilar insufficiency with vascular risk factors (sensitivity 94%, specificity 95% for vertebral artery stenosis). 2, 3

Step 5: Laboratory Testing

Fingerstick glucose immediately (hypoglycemia is the most frequently identified unexpected abnormality). 2, 3

Basic metabolic panel only if history or examination suggests specific abnormalities (e.g., dehydration, electrolyte imbalance). 2, 3

Avoid routine comprehensive laboratory panels—they rarely change management in isolated dizziness. 2, 3

Step 6: Treatment Based on Diagnosis

BPPV

  • Canalith repositioning procedure (Epley maneuver) immediately after positive Dix-Hallpike: 80% success after 1–3 treatments, 90–98% with repeat maneuvers. 1, 2
  • No imaging or medication needed for typical cases. 1, 2
  • Avoid vestibular suppressants (meclizine, dimenhydrinate, benzodiazepines)—they delay central compensation and do not correct the mechanical problem. 2, 3
  • Counsel on recurrence risk: 10–18% at 1 year, up to 36% long-term. 1, 2
  • Fall risk: BPPV increases fall risk 12-fold in elderly patients; assess home safety and consider vestibular rehabilitation if symptoms persist after 2–3 repositioning attempts. 1, 2

Vestibular Neuritis

  • Vestibular suppressants (antiemetics, benzodiazepines) for acute phase only (first 24–48 hours). 4, 5
  • Early vestibular rehabilitation therapy to promote central compensation. 1, 2

Ménière's Disease

  • Salt restriction and diuretics (e.g., hydrochlorothiazide). 1, 4
  • Intratympanic treatments (gentamicin, corticosteroids) for refractory cases. 1, 2
  • Audiogram to document fluctuating low-to-mid frequency sensorineural hearing loss. 2, 3

Vestibular Migraine

  • Migraine prophylaxis (beta-blockers, tricyclic antidepressants, topiramate) and lifestyle modifications (sleep hygiene, trigger avoidance). 1, 2
  • Acute treatment: naproxen 500–550 mg + sumatriptan 50–100 mg orally (avoid in pregnancy/breastfeeding). 3

Posterior Circulation Stroke

  • Immediate MRI and neurologic consultation. 1, 2
  • Activate stroke protocol if within treatment window. 2, 3

Common Pitfalls to Avoid

  • Relying on symptom quality ("spinning" vs. "lightheadedness")—focus on timing and triggers instead. 1, 2
  • Assuming normal neurologic exam excludes stroke—75–80% of posterior circulation strokes have no focal deficits. 1, 2
  • Overuse of imaging—routine CT or MRI for isolated dizziness has <1–4% yield and often produces incidental findings. 1, 2
  • Failing to perform Dix-Hallpike—BPPV is the most common cause and is easily diagnosed and treated at the bedside. 1, 2
  • Using CT instead of MRI when stroke is suspected—CT misses most posterior circulation infarcts. 1, 2
  • Not assessing fall risk in elderly patients—dizziness increases fall risk 12-fold; 9% of elderly patients have BPPV, and three-fourths have fallen within 3 months. 1, 2
  • Prescribing vestibular suppressants for BPPV—they are unnecessary and delay recovery. 2, 3

References

1
Guideline

Approach to Managing a Patient Presenting with Dizziness

Praxis Medical Insights: Practical Summaries of Clinical Guidelines, 2026

2
Guideline

Initial Workup for Dizziness

Praxis Medical Insights: Practical Summaries of Clinical Guidelines, 2025

3
Guideline

Evaluation of Dizziness Based on Cited Facts

Praxis Medical Insights: Practical Summaries of Clinical Guidelines, 2026

4
Research

Dizziness: Approach to Evaluation and Management.

American family physician, 2017

Related Questions

How do you evaluate and manage vertigo (dizziness) on a video visit?
How do you differentiate vertigo from dizziness?
What is the recommended evaluation and management for a patient presenting with dizziness, bilateral lower limb weakness, and blurred vision?
What is the initial management for a patient presenting with dizziness?
What are the causes of vertigo (dizziness)?
Will a patient already on chronic opioid therapy require additional or higher‑dose opioids after surgery, and what is this phenomenon called?
In a patient with angina who is already taking isosorbide mononitrate, topical nitroglycerin and diltiazem, can carvedilol be initiated as a first‑line anti‑anginal beta‑blocker, and what starting dose and monitoring parameters are recommended?
What is the appropriate management of tachycardia in a patient with hyperthyroidism, including antithyroid therapy, rate control, and definitive treatment?
What is the recommended monitoring schedule for a patient with stage 3b chronic kidney disease (CKD) (estimated glomerular filtration rate (eGFR) 30‑44 mL/min/1.73 m²)?
Should nifedipine be added to a patient with angina who is already receiving isosorbide mononitrate, topical nitroglycerin, diltiazem, and carvedilol?
What does an elevated red cell distribution width indicate and what is the appropriate diagnostic work‑up and management?

Professional Medical Disclaimer

This information is intended for healthcare professionals. Any medical decision-making should rely on clinical judgment and independently verified information. The content provided herein does not replace professional discretion and should be considered supplementary to established clinical guidelines. Healthcare providers should verify all information against primary literature and current practice standards before application in patient care. Dr.Oracle assumes no liability for clinical decisions based on this content.

Have a follow-up question?

Our Medical A.I. is used by practicing medical doctors at top research institutions around the world. Ask any follow up question and get world-class guideline-backed answers instantly.

Ask Question