What is the recommended inpatient evaluation and workup for a patient presenting with vertigo, including admission criteria, history, physical examination, laboratory studies, neuroimaging, and initial management?

Inpatient Workup for Vertigo

Admission Criteria

Most patients with vertigo do not require inpatient admission; reserve hospitalization for those with confirmed or suspected central causes, high-risk vascular profiles, or inability to ambulate safely. 1

Admit patients with any of the following red-flag features:

• Age >50 years with vascular risk factors (hypertension, diabetes, atrial fibrillation, prior stroke) presenting with acute vestibular syndrome, even if neurologic exam is normal—11-25% harbor posterior circulation stroke 1
• Focal neurological deficits (dysarthria, limb weakness, sensory loss, diplopia, Horner's syndrome) 1, 2
• Severe postural instability with inability to stand or walk 1, 2
• New severe headache accompanying vertigo 1
• Downbeating or purely vertical nystagmus without torsional component 1, 2
• Direction-changing nystagmus without head position changes 1, 2
• Sudden unilateral hearing loss 1
• Abnormal HINTS examination suggesting central cause (normal head impulse test, direction-changing nystagmus, skew deviation) 1, 3

History: Timing and Triggers Framework

Abandon the traditional approach of asking patients to describe their "dizziness" or "spinning"—this is diagnostically unreliable. 1, 3 Instead, classify vertigo by temporal pattern and triggers:

Acute Vestibular Syndrome (Days to Weeks)

• Continuous severe vertigo with nausea, vomiting, intolerance to head motion 3
• Differential: vestibular neuritis (41% of peripheral vertigo), labyrinthitis, posterior circulation stroke (25% overall, 75% in high-risk vascular patients) 1, 3
• Critical pitfall: 75-80% of posterior circulation strokes present WITHOUT focal neurologic deficits 1

Triggered Episodic Vestibular Syndrome (Seconds to <1 Minute)

• Brief episodes provoked by specific head position changes 1, 3
• Differential: BPPV (42% of all vertigo cases), superior canal dehiscence, perilymphatic fistula 1, 3

Spontaneous Episodic Vestibular Syndrome (Minutes to Hours)

• Episodes lasting 20 minutes to hours without positional triggers 3
• Differential: vestibular migraine (14% of vertigo cases, markedly under-recognized), Ménière's disease, vertebrobasilar TIA 1, 3

Chronic Vestibular Syndrome (Weeks to Months)

• Persistent symptoms 3
• Differential: medication side effects (leading reversible cause), anxiety/panic disorder, posterior fossa mass 1, 3

Directed History Elements

Auditory symptoms:

• Fluctuating hearing loss, tinnitus, aural fullness → Ménière's disease 1, 3
• Stable or absent hearing loss → vestibular migraine 1

Migrainous features:

• Headache, photophobia, phonophobia during ≥50% of vertigo episodes → vestibular migraine 1, 3

Vascular risk assessment:

• Document age, hypertension, diabetes, atrial fibrillation, prior stroke 1, 3

Medication review:

• Antihypertensives, sedatives, anticonvulsants, psychotropic agents are the most common reversible cause of chronic dizziness 1, 3

Physical Examination

Neurologic Examination

Perform comprehensive cranial nerve, motor, sensory, cerebellar, and gait testing. 1 However, recognize that a normal neurologic exam does NOT exclude stroke—most posterior circulation strokes lack focal deficits. 1

HINTS Examination (for Acute Vestibular Syndrome with Nystagmus)

The HINTS examination (Head Impulse, Nystagmus, Test of Skew) has 100% sensitivity for stroke when performed by trained practitioners—superior to early MRI (46% sensitivity). 1, 3 However, when performed by non-experts in the emergency department, HINTS is unreliable and should NOT be used as the sole decision tool. 1, 4

Central features (require urgent MRI):

• Normal head impulse test 1, 3
• Direction-changing or vertical nystagmus 1, 2, 3
• Skew deviation on alternate cover testing 1, 3

Peripheral features:

• Abnormal head impulse test (corrective saccade) 1
• Unidirectional horizontal-torsional nystagmus 1, 2
• No skew deviation 1

Dix-Hallpike Maneuver (for Triggered Episodic Vertigo)

Perform bilaterally as the gold standard for posterior canal BPPV. 1, 3

Positive peripheral (BPPV) findings:

• Latency period 5-20 seconds 1, 3
• Torsional upbeating nystagmus toward affected ear 1, 3
• Crescendo-decrescendo pattern, resolves within 60 seconds 1, 3
• Fatigues with repeated testing 1, 2

Red-flag central findings:

• Immediate onset without latency 1, 2
• Purely vertical nystagmus without torsional component 1, 2
• Persistent nystagmus that does not resolve 1, 2
• Does not fatigue with repeated testing 1, 2

Nystagmus Characteristics

Peripheral vertigo nystagmus:

• Horizontal with rotatory component 2
• Unidirectional 2
• Suppressed by visual fixation 2
• Fatigable 2

Central vertigo nystagmus:

• Pure vertical without torsional component 1, 2
• Direction-changing without head position changes 1, 2
• NOT suppressed by visual fixation 1, 2
• Does NOT fatigue 1, 2
• Gaze-evoked 1

Laboratory Studies

No routine laboratory testing is indicated for typical BPPV or peripheral vertigo. 3

Reserve laboratory tests for specific scenarios:

• Fingerstick glucose immediately (hypoglycemia is the most common unexpected abnormality) 1
• Basic metabolic panel only if history/exam suggests specific abnormalities 1
• Audiometry for unilateral hearing loss, tinnitus, or aural fullness 1, 3
• Autoimmune panels for bilateral fluctuating progressive hearing loss 3
• Serologic testing (Lyme, syphilis) for suspected infectious causes with fever, severe otalgia, or sudden bilateral hearing loss 3

Avoid routine comprehensive laboratory panels—they rarely change management. 1

Neuroimaging

When Imaging is NOT Indicated

Do NOT order imaging for:

• Typical BPPV with positive Dix-Hallpike and no red flags 1, 3
• Acute persistent vertigo with normal neurologic exam and peripheral HINTS pattern (by trained examiner) in low vascular risk patients 1
• Nonspecific dizziness without vertigo, ataxia, or neurologic deficits 1

CT head has <1% diagnostic yield for isolated dizziness and misses most posterior circulation infarcts (sensitivity 10-20%). 1

When MRI is MANDATORY

Order urgent MRI brain without contrast (with diffusion-weighted imaging) for:

• High vascular risk patients (age >50 with hypertension, diabetes, atrial fibrillation, prior stroke) with acute vestibular syndrome, even with normal neurologic exam 1, 3
• Abnormal neurologic examination 1, 3
• HINTS examination suggesting central cause 1, 3
• Any red-flag features listed above 1
• Unilateral or pulsatile tinnitus 1
• Asymmetric hearing loss 1
• Progressive neurologic symptoms 1

MRI with diffusion-weighted imaging has 4% diagnostic yield vs <1% for CT and is essential for detecting posterior circulation infarcts. 1

Special Imaging Considerations

MRI internal auditory canal WITH and WITHOUT contrast for:

• Chronic recurrent vertigo with unilateral hearing loss or tinnitus to exclude vestibular schwannoma 1
• Suspected Ménière's disease requiring definitive diagnosis 1

CT temporal bone (not routine) for:

• Conductive hearing loss without middle ear mass to detect otosclerosis, ossicular erosion, superior canal dehiscence 1

CTA or MRA head and neck for:

• Suspected vertebrobasilar insufficiency (94% sensitivity, 95% specificity for vertebral artery stenosis) 1
• Pulsatile tinnitus to evaluate vascular malformations, arterial dissection 1

Initial Management by Diagnosis

Confirmed BPPV

Perform Epley (canalith repositioning) maneuver immediately—80% success after 1-3 treatments, 90-98% with repeat maneuvers. 1, 3 Do NOT prescribe vestibular suppressants (meclizine, dimenhydrinate, benzodiazepines)—they prevent central compensation and delay recovery. 1, 3

Vestibular Neuritis

Offer limited course of vestibular suppressants ONLY during acute phase for symptomatic relief. 3 Early vestibular rehabilitation is essential to promote central compensation. 1

Ménière's Disease

Initiate low-sodium diet, avoid caffeine/alcohol/nicotine, ensure adequate hydration. 3 Consider diuretics for persistent symptoms. 1 Intratympanic gentamicin or endolymphatic sac decompression for refractory cases. 1

Vestibular Migraine

Migraine prophylaxis and lifestyle modifications. 1 Combination naproxen 500-550 mg + sumatriptan 50-100 mg for acute attacks (avoid in pregnancy/breastfeeding). 1

Suspected Posterior Circulation Stroke

Immediate neurology consultation, stroke protocol activation, urgent MRI with diffusion-weighted imaging. 1 Do NOT delay imaging for HINTS examination if high-risk features present. 1, 4

Critical Pitfalls to Avoid

• Assuming normal neurologic exam excludes stroke—75-80% of posterior circulation strokes have no focal deficits 1
• Relying on patient description of "spinning" vs "lightheadedness"—focus on timing and triggers instead 1, 3
• Using HINTS examination without proper training—it is unreliable when performed by non-experts 1, 4
• Ordering CT instead of MRI for suspected stroke—CT misses most posterior circulation infarcts 1
• Prescribing vestibular suppressants for BPPV—they delay recovery 1, 3
• Overlooking medication side effects as the most common reversible cause of chronic dizziness 1, 3
• Missing vestibular migraine—it accounts for 14% of vertigo cases but is markedly under-recognized 1, 3
• Failing to recognize that 10% of cerebellar strokes mimic peripheral vestibular disorders 2