What is the recommended approach to assess and manage a patient presenting with vertigo?

Vertigo Assessment: Evidence-Based Approach

Begin vertigo assessment by categorizing patients into one of three timing-and-trigger syndromes—acute vestibular syndrome (AVS), spontaneous episodic vestibular syndrome, or triggered episodic vestibular syndrome—as this framework directly guides your physical examination and distinguishes benign peripheral causes from dangerous central pathology. 1, 2

Initial Clinical Categorization

The traditional approach of classifying dizziness by symptom quality (vertigo vs. presyncope vs. disequilibrium) is outdated and does not distinguish benign from dangerous causes 2. Instead, use timing and triggers:

1. Acute Vestibular Syndrome (AVS)

• Continuous vertigo lasting days with nausea/vomiting, gait instability, nystagmus, and head-motion intolerance 3
• Key distinction needed: Vestibular neuritis (benign) vs. posterior circulation stroke (life-threatening)

2. Spontaneous Episodic Vestibular Syndrome

• Recurrent vertigo episodes without positional triggers
• Consider: Vestibular migraine, Menière's disease, transient ischemic attack 3, 2

3. Triggered Episodic Vestibular Syndrome

• Vertigo provoked by head position changes
• Most commonly: Benign paroxysmal positional vertigo (BPPV) 4

Critical Physical Examination Maneuvers

For AVS (Continuous Vertigo):

HINTS examination (Head Impulse, Nystagmus, Test of Skew) is the gold standard—but only if you are properly trained 1. The 2023 GRACE-3 guidelines emphasize that untrained emergency clinicians applying HINTS have poor accuracy, making it not standard of care without proper training 1.

If trained in HINTS:

• Use HINTS in patients with nystagmus to distinguish central from peripheral causes 1
• Add finger rub test to further exclude stroke 1
• In patients without nystagmus, assess severity of gait unsteadiness 1

Red flags suggesting central (stroke) etiology:

• Downbeating nystagmus on Dix-Hallpike (especially without torsional component) 4
• Direction-changing nystagmus without head position changes 4
• Gaze-evoked nystagmus 4
• Associated neurologic symptoms: dysarthria, dysmetria, dysphagia, sensory/motor deficits, Horner's syndrome 4

For Triggered Episodic Syndrome (Positional Vertigo):

Perform the Dix-Hallpike maneuver as your primary diagnostic test 4:

• Bring patient from upright to supine with head turned 45° to one side, neck extended 20°, affected ear down
• Positive test: Torsional, upbeating nystagmus with vertigo = posterior canal BPPV 4
• Repeat with opposite ear if initial maneuver negative 4

If Dix-Hallpike shows horizontal or no nystagmus:

• Perform supine roll test to assess for lateral semicircular canal BPPV 4

Imaging Decisions

Do NOT order imaging for:

• BPPV meeting diagnostic criteria without additional neurologic symptoms 4
• AVS if trained clinician performs HINTS and findings suggest peripheral cause 1

Order MRI (not CT) when:

• Central or equivocal HINTS examination 1
• AVS with associated neurologic symptoms (12% diagnostic yield vs. 4% in isolated dizziness) 3
• Concern for transient ischemic attack in spontaneous episodic syndrome—use CT angiography or MR angiography 1

CT has extremely low yield (~2% positivity rate) in undifferentiated vertigo and should not be routinely used 3, 1.

Immediate Management

For BPPV (Posterior Canal):

• Treat with Epley maneuver (canalith repositioning procedure) 4, 1
• Do NOT recommend postprocedural postural restrictions 4
• Do NOT routinely prescribe vestibular suppressants (antihistamines/benzodiazepines) 4

For Vestibular Neuritis:

• Consider short-term steroids 1
• Vestibular rehabilitation may be offered 4

Risk Stratification

Assess all vertigo patients for fall risk and modifying factors 4:

• Impaired mobility or balance
• CNS disorders
• Lack of home support
• Age >65 (9% have undiagnosed BPPV; three-fourths had fallen within 3 months) 4

Follow-Up Protocol

Reassess within 1 month to document resolution or persistence 4. For persistent symptoms, evaluate for:

• Unresolved BPPV
• Underlying peripheral vestibular disorders
• Central nervous system disorders 4

Common Pitfalls

• Avoid relying on symptom quality alone (e.g., "spinning" vs. "lightheadedness")—this does not distinguish dangerous from benign causes 2
• Do not use HINTS if untrained—misapplication leads to missed strokes 1
• Do not order CT for vertigo workup—it misses posterior circulation strokes and has minimal yield 3, 1
• Do not skip the Dix-Hallpike test in positional vertigo—it's both diagnostic and guides treatment 4