How should I evaluate and manage a patient who presents with dizziness?

Evaluation of Dizziness

Categorize dizziness by timing and triggers—not by the patient's subjective description—to determine the specific vestibular syndrome and guide your targeted physical examination and management. 1

Initial Classification by Timing and Triggers

The American Academy of Otolaryngology-Head and Neck Surgery emphasizes that relying on patient descriptions like "spinning" versus "lightheadedness" is unreliable and should be avoided. 1, 2 Instead, classify dizziness into one of four vestibular syndromes:

1. Triggered Episodic Vestibular Syndrome (seconds to <1 minute)

• Benign Paroxysmal Positional Vertigo (BPPV) is the most common cause, accounting for 42% of all vertigo cases. 1
• Symptoms are triggered by specific head position changes relative to gravity. 1
• Perform the Dix-Hallpike maneuver bilaterally as the gold standard diagnostic test. 1, 3
• Positive findings include: 5-20 second latency, torsional upbeating nystagmus toward the affected ear, and symptoms resolving within 60 seconds. 1, 3
• If Dix-Hallpike is negative, perform the supine roll test to assess for horizontal canal BPPV (10-15% of cases). 1

2. Acute Vestibular Syndrome (days to weeks of constant symptoms)

• This is the highest-risk category requiring immediate differentiation between peripheral (vestibular neuritis) and central (posterior circulation stroke) causes. 1
• Critical fact: 75-80% of patients with posterior circulation stroke have NO focal neurologic deficits, so a normal neurologic exam does NOT exclude stroke. 1
• Perform the HINTS examination (Head Impulse, Nystagmus, Test of Skew) if you are specifically trained—it has 100% sensitivity for stroke when performed by experts, superior to early MRI (46% sensitivity). 1
• However, HINTS is unreliable when performed by non-experts or emergency physicians. 1

3. Spontaneous Episodic Vestibular Syndrome (minutes to hours)

• Vestibular migraine accounts for 14% of all vertigo cases but is markedly under-recognized, especially in young patients. 1
• Ask about current or past migraine history, family history of migraine, and associated symptoms (headache, photophobia, phonophobia). 1
• Ménière's disease presents with fluctuating low-to-mid frequency sensorineural hearing loss, tinnitus, and aural fullness. 1
• Key distinction: Ménière's has fluctuating hearing loss; vestibular migraine has stable or absent hearing loss. 1

4. Chronic Vestibular Syndrome (weeks to months)

• Medication side effects are the leading reversible cause—systematically review antihypertensives, sedatives, anticonvulsants, and psychotropic drugs. 1
• Screen for psychiatric symptoms (anxiety, panic disorder, depression), which are common causes of chronic dizziness. 1
• Consider posttraumatic vertigo if there is a history of head trauma. 1

Essential History Elements

Duration and onset:

• Seconds suggest BPPV. 1
• Minutes to hours suggest vestibular migraine or Ménière's. 1
• Days to weeks suggest vestibular neuritis or stroke. 1

Associated symptoms:

• Hearing loss, tinnitus, or aural fullness point to Ménière's disease. 1
• Headache with photophobia and phonophobia suggest vestibular migraine. 1
• Sudden unilateral hearing loss is a red flag requiring urgent neuroimaging. 1

Vascular risk factors:

• Age >50, hypertension, diabetes, atrial fibrillation, or prior stroke increase stroke risk to 11-25% even with normal neurologic exam. 1

Physical Examination

For all patients:

• Observe for spontaneous nystagmus. 3
• Perform a complete neurologic examination including cranial nerves, cerebellar testing, and gait assessment. 1
• Check orthostatic vital signs. 4, 5

For triggered episodic symptoms:

• Perform Dix-Hallpike maneuver bilaterally. 1, 3
• If negative, perform supine roll test. 1

For acute vestibular syndrome:

• Perform HINTS examination only if specifically trained. 1
• Components suggesting central vertigo: normal head impulse test, direction-changing or vertical nystagmus, present skew deviation. 1

Imaging Decisions

When imaging is NOT indicated:

• Typical BPPV with positive Dix-Hallpike test and no red flags. 1, 2
• 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

When MRI brain without contrast IS indicated:

• Abnormal neurologic examination. 1, 3
• HINTS examination suggesting central cause. 1, 3
• High vascular risk patients (age >50 with hypertension, diabetes, atrial fibrillation, or prior stroke) with acute vestibular syndrome, even with normal neurologic examination—11-25% may have posterior circulation stroke. 1
• Unilateral or pulsatile tinnitus. 1
• Asymmetric hearing loss. 1
• Focal neurological deficits. 1
• Sudden hearing loss. 1
• Inability to stand or walk. 1
• Downbeating or other central nystagmus patterns. 1
• New severe headache accompanying dizziness. 1
• Progressive neurologic symptoms. 1

Critical imaging facts:

• CT head has <1% diagnostic yield for isolated dizziness and misses most posterior circulation infarcts (sensitivity only 10-20%). 1
• MRI with diffusion-weighted imaging has 4% diagnostic yield versus <1% for CT and is far superior for detecting posterior circulation infarcts. 1
• Never substitute CT for MRI when stroke is suspected. 1

Treatment Based on Diagnosis

BPPV:

• Perform canalith repositioning procedures (Epley maneuver) immediately as first-line treatment. 1, 3
• Success rate: 80% after 1-3 treatments, 90-98% with repeat maneuvers. 1
• No imaging or medication is needed for typical cases. 1
• Counsel patients about 10-18% recurrence risk at 1 year, up to 36% long-term. 1, 3
• Avoid vestibular suppressants (meclizine, dimenhydrinate, benzodiazepines)—they do not correct the mechanical pathology and delay central compensation. 1

Ménière's disease:

• Salt restriction and diuretics. 1, 5
• Intratympanic treatments for refractory cases. 1

Vestibular migraine:

• Migraine prophylaxis and lifestyle modifications. 1

Vestibular neuritis:

• Vestibular suppressants limited to acute phase only. 1
• Early vestibular rehabilitation therapy to promote central compensation. 1

Persistent dizziness after initial treatment:

• Refer for vestibular rehabilitation therapy, which significantly improves gait stability compared to medication alone, particularly beneficial for elderly patients or those with heightened fall risk. 1

Special Considerations for Elderly Patients

• Dizziness increases fall risk 12-fold in elderly patients. 1
• BPPV is present in 9% of elderly patients referred for geriatric evaluation—three-fourths had fallen within the prior 3 months. 1
• Document number of falls in past year, circumstances, and injuries sustained. 1
• Counsel on home safety assessment and activity restrictions until resolved. 1

Critical Pitfalls to Avoid

• Do not rely on patient descriptions of "spinning" versus "lightheadedness"—focus on timing and triggers instead. 1, 2
• Do not assume normal neurologic exam excludes stroke—75-80% of posterior circulation strokes have no focal deficits. 1
• Do not use CT instead of MRI when stroke is suspected—CT misses most posterior circulation infarcts. 1
• Do not fail to perform Dix-Hallpike in patients with brief positional episodes, even without classic "spinning" description—50% of BPPV patients describe atypical symptoms. 1
• Do not rely on HINTS examination in the emergency department without expert training—obtain MRI for high-risk patients regardless of HINTS results. 1
• Do not order routine imaging for isolated dizziness—diagnostic yield is <1% for CT and only 4% for MRI. 1
• Do not overlook medication side effects as a leading reversible cause of chronic dizziness. 1

Laboratory Testing

• Check fingerstick glucose immediately—hypoglycemia is the most frequently identified unexpected abnormality. 1
• Consider basic metabolic panel only if history or examination suggests specific abnormalities. 1
• Avoid routine comprehensive laboratory panels—they rarely change management. 1