Evaluation of Episodic Vertigo with Syncope and Headache

Risk Stratification and Clinical Significance

Syncope with vertigo is atypical for benign peripheral vestibular disorders and suggests either vertebrobasilar insufficiency or cardiac arrhythmia. 3
The absence of bowel/bladder incontinence does not exclude serious pathology—this finding is more specific for seizure but its absence is non-discriminatory. 6
High-risk features for serious cardiac events include abnormal ECG, history of cardiovascular disease, age >65 years, lack of prodrome, or syncope during exertion—any of these warrant immediate cardiac evaluation. 8

In the Dix-Hallpike maneuver, peripheral causes (BPPV) show torsional upbeating nystagmus with 5-20 second latency, crescendo-decrescendo pattern, and resolution within 60 seconds, while central causes show immediate onset, persistent purely vertical nystagmus without torsional component. 4, 5
When performed by trained practitioners, the HINTS examination (Head Impulse, Nystagmus, Test of Skew) has 100% sensitivity for posterior circulation stroke versus 46% for early MRI. 4

CT head has very low diagnostic yield (<1%) for isolated dizziness and sensitivity of only 20-40% for posterior circulation infarcts. 4
MRI with diffusion-weighted imaging has significantly higher diagnostic yield (4% in isolated dizziness, up to 16% when changing diagnosis). 4
CT is particularly poor at detecting posterior circulation infarcts, which are the most common central cause of acute dizziness. 4

12-lead ECG should be obtained immediately to look for conduction abnormalities, prolonged QT, Brugada pattern, and pre-excitation. 9, 8
Echocardiography is indicated when structural heart disease is suspected or syncope suggests cardiovascular cause. 9, 8
Prolonged ECG monitoring should be considered if initial ECG shows abnormalities or high suspicion for arrhythmic syncope. 9

75-80% of patients with acute vestibular syndrome from posterior circulation infarct have no focal neurologic deficits on standard examination. 4

For vertebrobasilar insufficiency, vascular imaging (CTA or MRA of neck vessels) should be performed to evaluate for stenosis or dissection. 7, 1
Vestibular migraine diagnosis requires migraine symptoms (photophobia, phonophobia, visual aura) during at least two vertiginous episodes. 7, 5
For cardiac arrhythmia, treatment should be specific to the underlying arrhythmia (pacemaker for bradycardia, ablation for tachyarrhythmias, ICD for ventricular arrhythmias). 3, 6
Canalith repositioning procedures (Epley maneuver) for BPPV have success rates of 90-98%. 4, 5