How should I evaluate and manage a patient who developed dizziness after a fall?

Evaluation and Management of Dizziness After a Fall

Immediately classify the patient into one of three vestibular syndromes—Acute Vestibular Syndrome, Triggered Episodic Vestibular Syndrome, or Spontaneous Episodic Vestibular Syndrome—to distinguish benign peripheral causes from dangerous central pathology like stroke. 1

Immediate History and Risk Stratification

Ask specific questions in order of priority: age, number of previous falls, duration of dizzy episodes, specific triggers (especially head position changes), time spent on floor after fall, loss of consciousness, near-syncope or orthostatic symptoms, associated symptoms (hearing loss, headache, neurologic deficits), feeling unsteady when standing or walking, and worry about falling. 1

Critical Red Flags Requiring Urgent Imaging

Obtain MRI brain without contrast immediately if any of the following are present:

• Focal neurological deficits (dysarthria, limb weakness, sensory loss, diplopia, Horner's syndrome) 1, 2
• Sudden unilateral hearing loss 1, 2
• Inability to stand or walk 1, 2
• New severe headache accompanying dizziness 1, 2
• Downbeating or purely vertical nystagmus 1, 2
• Direction-changing nystagmus 1, 2
• Age >50 years with vascular risk factors (hypertension, diabetes, atrial fibrillation, prior stroke), even with normal neurologic exam 1, 2

Fall Risk Assessment in Elderly Patients

Dizziness increases fall risk 12-fold in elderly patients. 3 Among elderly patients with undiagnosed BPPV, 75% had fallen within the prior 3 months. 1, 3

Use standardized tools to assess fall risk: Get Up and Go test, Tinetti Balance Assessment, or Berg Balance Scale for patients with positive screening responses. 1

Physical Examination

Essential Bedside Maneuvers

Perform the Dix-Hallpike maneuver bilaterally as the gold standard for diagnosing BPPV—the most common cause of positional dizziness after falls (36.3% of cases). 3, 2 Look for:

• Latency period of 5-20 seconds 2
• Torsional, upbeating nystagmus toward the affected ear 2
• Vertigo and nystagmus that increase then resolve within 60 seconds 2

If Dix-Hallpike is negative, perform the supine roll test to assess for horizontal canal BPPV. 2

HINTS Examination for Acute Persistent Vertigo

For patients with continuous vertigo lasting hours to days, the HINTS examination (Head Impulse, Nystagmus, Test of Skew) has 100% sensitivity for detecting stroke when performed by trained practitioners, compared to only 46% sensitivity for early MRI. 1, 2 However, emergency physicians achieve inadequate sensitivity—do not rely on HINTS alone in the ED; obtain urgent MRI for high-risk patients regardless of HINTS results. 2

Orthostatic Vital Signs

Check orthostatic blood pressure and heart rate, as medication side effects (especially antihypertensives, diuretics, sedatives) are a leading reversible cause of dizziness in elderly patients. 3, 4

Imaging Decisions

When Imaging Is NOT Indicated

No imaging is needed for:

• Brief episodic vertigo with typical BPPV features and positive Dix-Hallpike test 1, 2
• Acute persistent vertigo with normal neurologic exam and HINTS consistent with peripheral vertigo by trained examiner 1, 2
• Nonspecific dizziness without vertigo, ataxia, or neurologic deficits 2

When MRI Is Required

MRI brain without contrast is the preferred modality (not CT, which has <1% diagnostic yield for posterior circulation strokes). 1, 2 MRI is indicated for:

• Abnormal neurologic examination 1, 2
• HINTS examination suggesting central cause 1, 2
• High vascular risk patients (age >50 with hypertension, diabetes, atrial fibrillation, prior stroke), even with normal exam—11-25% may have posterior circulation stroke 2
• Unilateral or pulsatile tinnitus 1, 2
• Asymmetric hearing loss 1, 2

CT head misses the majority of posterior circulation infarcts (sensitivity only 10-20%) and should not substitute for MRI when stroke is suspected. 2

Immediate Management Based on Diagnosis

BPPV (Most Common After Falls)

Perform the Epley maneuver immediately for confirmed BPPV—80% success after 1-3 treatments, rising to 90-98% with repeat maneuvers. 1, 2, 4 No imaging or medication is needed for typical BPPV cases. 1, 2

Avoid vestibular suppressants (meclizine, dimenhydrinate, benzodiazepines) as they do not correct the mechanical pathology and may delay central compensation. 5, 2

Persistent Dizziness After Initial Treatment

Refer for vestibular rehabilitation therapy when vertigo persists after 2-3 repositioning attempts—this significantly improves gait stability compared to medication alone, particularly beneficial for elderly patients or those with heightened fall risk. 1, 2

Post-Traumatic Considerations

After head trauma, patients may develop post-traumatic vertigo with persistent symptoms including vertigo, disequilibrium, tinnitus, and headache. 3, 6 BPPV is particularly common after head trauma and should be actively sought with positional testing. 6, 7

Safety Assessment Before Discharge

Before discharge, patients must demonstrate:

• Ability to rise from bed independently 1
• Steady ambulation out of examination area 1
• Understanding of fall precautions 1

Counsel specifically about:

• Sitting or lying down immediately when feeling dizzy 1
• Using assistive devices if balance affected 1
• Avoiding driving during acute episodes 1
• Home safety modifications (removing tripping hazards, installing grab bars) 1
• Home supervision if elderly and frail 3

Follow-Up

Reassess within one month after initial treatment to document resolution or persistence of symptoms. 2 Counsel about recurrence risk (BPPV recurs in approximately 50% of patients within 5 years) and the importance of returning promptly if symptoms recur for repeat repositioning procedures. 2

Common Pitfalls to Avoid

• Assuming normal neurologic exam excludes stroke—75-80% of posterior circulation stroke patients with acute vestibular syndrome have no focal neurologic deficits. 1, 2
• Relying on CT imaging for suspected stroke—it frequently misses posterior circulation strokes. 1, 2
• Prescribing vestibular suppressants for BPPV—they are unnecessary and may impair central compensation. 5, 2
• Failing to perform positional testing—even when patients don't describe classic "spinning," 50% of BPPV patients use vague terms like "lightheadedness" or "off-balance." 2
• Overlooking medication review—polypharmacy is a major contributor to dizziness in elderly patients. 3, 4