Initial Approach to Vertigo Syndrome

Classification and Diagnosis

The American Academy of Otolaryngology-Head and Neck Surgery recommends classifying vertigo based on its temporality and triggering factors into four categories: episodic triggered vertigo (<1 minute), episodic spontaneous vertigo (minutes to hours), acute vestibular syndrome (days), or chronic vertigo (weeks to months), followed by specific physical maneuvers and selective imaging 1.
The initial temporal classification is more useful diagnostically than the patient's subjective description of "dizziness" or "spinning", with a focus on temporality and triggers being more informative than the description itself 1, 2.
Episodic triggered vertigo (seconds to <1 minute) suggests benign paroxysmal positional vertigo (BPPV), superior canal dehiscence, or perilymphatic fistula, with brief episodes provoked by specific head position changes 1.
Episodic spontaneous vertigo (minutes to hours) indicates Meniere's disease, vestibular migraine, or vertebrobasilar insufficiency, with episodes lasting 20 minutes to hours without provocation 1.
Acute vestibular syndrome (days) suggests vestibular neuritis, labyrinthitis, or posterior circulation stroke, with continuous and severe vertigo lasting days 1.
Chronic vertigo (weeks to months) may indicate anxiety disorder, medication effects, or posterior fossa mass, with persistent symptoms 1.

Identify specific characteristics rather than vague descriptions, including auditory symptoms such as hearing loss, tinnitus, or aural fullness, which suggest Meniere's disease (fluctuating hearing loss) versus vestibular migraine (stable hearing) 1, 2.
Migrainous symptoms such as headache, photophobia, and phonophobia point to vestibular migraine, which represents 14% of all vertigo cases but is often underdiagnosed 2.
Vascular risk factors such as age >50 years, hypertension, diabetes, atrial fibrillation, or previous stroke increase the risk of central cause 2.
Review of medications, as medication side effects are a primary and reversible cause of chronic vestibular syndrome, particularly antihypertensives, sedatives, anticonvulsants, and psychotropic medications 1, 2.

The Dix-Hallpike maneuver is the gold standard for diagnosing posterior canal BPPV, with diagnostic criteria including a latency period of 5-20 seconds, torsional nystagmus beating towards the affected ear, and vertigo and nystagmus that increase and then resolve within 60 seconds 1, 3.
The HINTS (Head Impulse, Nystagmus, Test of Skew) examination has 92.9% sensitivity and 83.4% specificity for central causes when performed by a trained clinician, surpassing the sensitivity of early MRI (100% vs 46%) 1, 2.
Findings suggesting central cause include normal head impulse test, direction-changing or vertical nystagmus, and skew deviation 1, 2, 3.

Indicators of peripheral vertigo include auditory symptoms, episodes triggered by specific head movements, and no neurological symptoms beyond vertigo 1.
Red flags for central cause (requiring urgent imaging) include cranial nerve deficits, severe postural instability, age >50 years with vascular risk factors, inability to stand or walk, downbeating nystagmus or other central patterns, severe new headache, and sudden unilateral hearing loss 1, 2, 4.

No imaging is needed for brief episodic vertigo with typical BPPV characteristics and positive Dix-Hallpike, or for acute vestibular syndrome with normal neurological examination and HINTS consistent with peripheral vertigo by a trained examiner 1, 3.
MRI of the brain with and without IV contrast is urgently required for patients with positive Romberg test, central signs on HINTS examination, severe postural instability, focal neurological deficits, or high-risk vascular patients with acute vestibular syndrome, even with normal neurological examination 1, 2.

No routine blood tests (complete blood count, serum chemistry) are recommended as standard practice for diagnosing BPPV, which accounts for 85-95% of vertigo cases, due to the clinical nature of the diagnosis 1.
Reserve laboratory tests for specific clinical scenarios, including audiometry for auditory symptoms suggesting Meniere's disease or other inner ear pathology 4, autoimmune panels for bilateral fluctuating progressive hearing loss that may respond to steroids 3, and serologic tests for suspected infectious causes (Lyme disease, otosyphilis) presenting with vertigo and severe otalgia, fever, or sudden bilateral hearing loss.

For confirmed BPPV, perform canalith repositioning procedures (Epley maneuver) immediately as first-line treatment, with 80% success after 1-3 treatments and 90-98% success with repeated maneuvers 1, 2, 3.
For acute vestibular syndrome (vestibular neuritis), offer a limited course of vestibular suppressants only during acute attacks for symptomatic management of vertigo 4.
For Meniere's disease, educate patients on dietary and lifestyle modifications, including low-sodium diet, avoiding excessive caffeine, alcohol, and nicotine, eating well-balanced meals, drinking plenty of water, and managing stress and getting sufficient exercise and sleep 4.

Do not rely solely on the patient's description of "spinning" instead of focusing on temporality and triggers, which are more useful diagnostically 1, 2.
Do not perform Dix-Hallpike when Romberg is positive, indicating central pathology that requires imaging first 1.
Do not misdiagnose central causes as BPPV, as CNS disorders masquerading as BPPV are found in 3% of treatment failures 1.
Do not assume a normal neurological examination excludes stroke in acute vestibular syndrome, especially in high-risk vascular patients 1, 2.