How should I evaluate and manage a patient presenting with dizziness?

Evaluation and Management of Dizziness

Begin by categorizing dizziness using timing and triggers—not the patient's subjective description—to determine the specific vestibular syndrome and guide your physical examination and management strategy. 1, 2

Initial History: Focus on Timing and Triggers

The traditional approach of asking patients to describe their dizziness as "spinning" versus "lightheadedness" is unreliable and should be abandoned. 1 Instead, structure your history around these key elements:

Duration of Episodes

• Seconds (<1 minute): Suggests BPPV, which accounts for 42% of all vertigo cases 1
• Minutes to hours: Points toward vestibular migraine (14% of cases) or Ménière's disease 1
• Days to weeks: Indicates vestibular neuritis (41% of peripheral vertigo) or posterior circulation stroke 1

Triggers

• Head position changes: Classic for BPPV 1
• Standing from supine: Suggests orthostatic hypotension (cardiovascular cause, not vestibular) 1
• Spontaneous (no trigger): Consider vestibular migraine, Ménière's disease, or vestibular neuritis 1

Associated Symptoms

• Hearing loss, tinnitus, aural fullness: Strongly suggests Ménière's disease 1, 3
• Headache with photophobia/phonophobia: Points to vestibular migraine 1
• Neurologic symptoms (dysarthria, diplopia, weakness, numbness): Red flags for central causes requiring urgent imaging 1, 2

Vascular Risk Assessment

Document age >50, hypertension, diabetes, atrial fibrillation, and prior stroke—these increase posterior circulation stroke risk to 75% in acute vestibular syndrome. 1

Physical Examination: Targeted Bedside Testing

For Brief Episodic Symptoms (Suspected BPPV)

Perform the Dix-Hallpike maneuver bilaterally as your primary diagnostic test. 1, 2 Positive findings include:

• 5-20 second latency before symptoms begin 1, 3
• Torsional, upbeating nystagmus toward the affected ear 1
• Crescendo-decrescendo pattern resolving within 60 seconds 1

If Dix-Hallpike is negative, perform the supine roll test to assess for horizontal canal BPPV (10-15% of BPPV cases). 1

For Acute Persistent Vertigo (Days to Weeks)

Perform the HINTS examination (Head Impulse, Nystagmus, Test of Skew) if you are specifically trained in this technique. 1, 2 When performed by trained practitioners, HINTS has 100% sensitivity for detecting stroke—superior to early MRI (46% sensitivity). 1, 2

Critical caveat: HINTS is unreliable when performed by non-experts. 1 If you lack specific training, proceed directly to MRI for high-risk patients rather than relying on HINTS results. 1

Central features on HINTS examination include:

• Normal head impulse test 1
• Direction-changing or vertical nystagmus 1
• Skew deviation present 1

Complete Neurologic Examination

Perform cranial nerve testing, cerebellar assessment, and gait evaluation in all dizzy patients. 2, 3 A normal neurologic exam does NOT exclude stroke—75-80% of posterior circulation strokes present without focal deficits. 1, 2

Orthostatic Vital Signs

Check blood pressure and heart rate supine and after 3 minutes of standing to assess for orthostatic hypotension. 4, 5

Red Flags Requiring Urgent MRI

Order MRI brain without contrast immediately for any of the following: 1, 2

• Focal neurological deficits (dysarthria, limb weakness, diplopia, Horner's syndrome)
• Sudden unilateral hearing loss
• Inability to stand or walk
• Downbeating or purely vertical nystagmus
• Direction-changing nystagmus
• New severe headache accompanying dizziness
• Age >50 with vascular risk factors (even with normal exam)
• HINTS examination suggesting central cause (if performed by trained examiner)
• Unilateral or pulsatile tinnitus
• Asymmetric hearing loss

MRI with diffusion-weighted imaging is mandatory—CT head has <1% diagnostic yield for isolated dizziness and misses most posterior circulation infarcts (sensitivity only 10-20%). 1, 2

When Imaging Is NOT Indicated

Do not order imaging for: 1, 2

• Typical BPPV with positive Dix-Hallpike and no red flags
• Acute persistent vertigo in patients <50 years old with no vascular risk factors, normal neurologic exam, and peripheral HINTS pattern (by trained examiner)
• Nonspecific dizziness without vertigo, ataxia, or neurologic deficits

Medication Review

Systematically review all medications—medication side effects are the leading reversible cause of chronic dizziness. 1 Focus on:

• Antihypertensives
• Sedatives and benzodiazepines
• Anticonvulsants
• Psychotropic drugs
• Vestibular suppressants

Treatment Based on Diagnosis

BPPV (Most Common Cause)

Perform the Epley canalith repositioning maneuver immediately after positive Dix-Hallpike. 1, 2, 3 Success rates:

• 80% after 1-3 treatments 1, 3
• 90-98% with repeat maneuvers 1, 3

Do not prescribe vestibular suppressants (meclizine, dimenhydrinate) for BPPV—they do not address the mechanical pathology and delay central compensation. 1

Counsel patients about:

• 10-18% recurrence risk at 1 year, up to 36% long-term 2, 3
• 12-fold increased fall risk, especially in elderly 1
• Need for reassessment within 1 month 1

Vestibular Neuritis

• Limit vestibular suppressants to acute phase only (first 2-3 days) 5
• Refer for vestibular rehabilitation therapy early to promote central compensation 1, 5

Ménière's Disease

• Salt restriction and diuretics for persistent symptoms 1, 5
• Intratympanic treatments for refractory cases 1
• Obtain audiogram to document fluctuating low-to-mid frequency sensorineural hearing loss 1

Vestibular Migraine

• Migraine prophylaxis and lifestyle modifications 1, 2
• This diagnosis is extremely under-recognized, particularly in young patients 1

Persistent Dizziness After Initial Treatment

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

Common Diagnostic Pitfalls to Avoid

1. Relying on patient descriptions of "spinning" versus "lightheadedness"—focus on timing and triggers instead 1, 2
2. Assuming normal neurologic exam excludes stroke—most posterior circulation strokes lack focal deficits 1, 2
3. Using CT instead of MRI when stroke is suspected—CT misses most posterior circulation infarcts 1, 2
4. Failing to perform Dix-Hallpike in patients with brief positional symptoms 1, 2
5. Ordering routine imaging for isolated dizziness without red flags—diagnostic yield is <1% for CT and only 4% for MRI 1, 2
6. Not assessing fall risk in elderly patients with vestibular disorders—dizziness increases fall risk 12-fold 1
7. Overlooking medication side effects—the most common reversible cause of chronic dizziness 1