Evaluation of Dizziness

Diagnostic Approach

The initial approach to evaluating dizziness should categorize patients by timing and triggers rather than symptom quality, as this framework directly guides targeted physical examination and distinguishes benign peripheral vestibular disorders from dangerous central causes like stroke 1, 2
Classify dizziness into one of three vestibular syndromes: Acute Vestibular Syndrome (AVS), Triggered Episodic Vestibular Syndrome, and Spontaneous Episodic Vestibular Syndrome 1, 2

Acute Vestibular Syndrome (AVS) is characterized by acute persistent vertigo lasting days to weeks with constant symptoms, and key examination includes HINTS (Head Impulse, Nystagmus, Test of Skew) 1, 2
HINTS has 100% sensitivity for posterior circulation stroke when performed by trained practitioners, superior to early MRI (46% sensitivity) 1, 2
Triggered Episodic Vestibular Syndrome is characterized by brief episodes lasting seconds to <1 minute triggered by head movements, and perform Dix-Hallpike maneuver and supine roll test 1, 2
Spontaneous Episodic Vestibular Syndrome is characterized by episodes lasting minutes to hours without positional triggers, and associated symptoms guide diagnosis 1, 2

Duration and onset of dizziness: seconds (BPPV), minutes to hours (vestibular migraine, Ménière's), days to weeks (vestibular neuritis, stroke) 1, 2
Triggers: head position changes (BPPV), pressure changes (superior canal dehiscence), none (vestibular neuritis, stroke) 1, 2
Associated symptoms: hearing loss, tinnitus, aural fullness → Ménière's disease; headache, photophobia, phonophobia → vestibular migraine 1, 2
Complete neurologic examination is essential, including cranial nerves, cerebellar testing, and gait assessment 1, 2

No imaging is indicated for brief episodic vertigo with typical BPPV features and positive Dix-Hallpike, or acute persistent vertigo with normal neurologic exam and HINTS consistent with peripheral vertigo by trained examiner 1, 2
MRI brain without contrast is indicated for abnormal neurologic examination, HINTS examination suggesting central cause, high vascular risk patients with acute vestibular syndrome, unilateral or pulsatile tinnitus, and asymmetric hearing loss 1, 2
CT head has very low yield (<1% diagnostic yield for isolated dizziness) and should not be used instead of MRI when stroke is suspected 1

BPPV: canalith repositioning procedures (Epley maneuver) as first-line treatment, with success rates 90-98% 1, 2
Vestibular migraine: migraine prophylaxis and lifestyle modifications 1, 2
Ménière's disease: salt restriction and diuretics, and intratympanic dexamethasone or gentamicin for refractory cases 1, 2
Posterior circulation stroke: activate stroke protocol immediately and urgent neurology consultation 3

Ask about falls in the past year, feeling unsteady, and worry about falling, and perform detailed falls risk assessment (Get Up and Go test, Tinetti Balance Assessment) if positive responses 4