Initial Workup for Dizziness

Categorizing Dizziness by Timing and Triggers

The American Academy of Otolaryngology-Head and Neck Surgery recommends focusing on timing and triggers rather than the patient's subjective description of symptoms to categorize dizziness into specific vestibular syndromes, which will guide further diagnostic testing and management 1, 2, 3
The initial workup should categorize dizziness into one of four vestibular syndromes: Acute Vestibular Syndrome (AVS), Triggered Episodic Vestibular Syndrome, Spontaneous Episodic Vestibular Syndrome, and Chronic Vestibular Syndrome, with AVS being acute persistent dizziness lasting days to weeks 2

The American Academy of Otolaryngology-Head and Neck Surgery suggests that the duration and onset of symptoms, as well as positional triggers, are key elements in the history of patients with dizziness 1, 2, 4
Associated symptoms such as hearing loss or tinnitus may suggest Ménière's disease, while neurological symptoms like headache, diplopia, dysarthria, numbness, or weakness may indicate central causes 3, 5

The American Academy of Otolaryngology-Head and Neck Surgery recommends observing for spontaneous nystagmus in all patients with dizziness 1, 6
For suspected Benign Paroxysmal Positional Vertigo (BPPV), the Dix-Hallpike maneuver and supine roll test should be performed to assess for posterior and horizontal canal BPPV 4

The Journal of the American College of Radiology states that imaging studies are not routinely indicated for most cases of dizziness, but may be considered when neurological symptoms or signs are present, or when the HINTS examination suggests a central cause 3, 5, 7
MRI brain with diffusion-weighted imaging is preferred over CT for suspected stroke, and CT temporal bone may be used for suspected structural abnormalities of the ear 5, 8, 9

The Journal of the American College of Radiology warns against overuse of imaging in patients with clear peripheral causes of dizziness, and recommends performing appropriate bedside tests like the Dix-Hallpike maneuver or HINTS examination 3, 5, 7
It is also important to avoid missing stroke in patients with isolated dizziness, as 4% of isolated dizziness cases are due to stroke 5

The American College of Radiology suggests categorizing dizziness into one of four vestibular syndromes based on timing and triggers, including Triggered Episodic Vestibular Syndrome (t-EVS) and Chronic Vestibular Syndrome 10, 11

The American College of Radiology recommends that imaging is unnecessary for typical BPPV with positive Dix-Hallpike testing, but atypical features warrant MRI evaluation 10, 11, 12
A complete neurologic examination identifies focal deficits suggesting central pathology, and is recommended for all dizzy patients 10

The American College of Radiology indicates that MRI head without IV contrast is recommended for acute persistent vertigo with abnormal neurologic examination or HINTS examination suggesting central vertigo 11, 12
MRI head without IV contrast is also recommended for high vascular risk patients with acute persistent vertigo, even with normal neurologic examination 11, 12
The diagnostic yield of MRI in isolated dizziness is only 4%, with ischemic stroke being the most common finding (70% of positive cases), and two-thirds located in the posterior circulation 10, 12

The American College of Radiology suggests that risk factors for serious causes (stroke, TIA) include hypertension 11, atrial fibrillation 11, and non-whirling type of dizziness 11
Approximately 4% of isolated dizziness cases are due to stroke, and normal neurologic examination does not exclude posterior circulation infarct 10

For suspected Meniere disease, associated symptoms of hearing loss or tinnitus warrant MRI head and IAC with contrast to exclude vestibular schwannoma 11
For suspected cerebellar ataxia, MRI head without IV contrast or with contrast evaluates cerebellar atrophy or pathology 11

The American Academy of Otolaryngology-Head and Neck Surgery recommends performing the Dix-Hallpike maneuver for suspected BPPV, with diagnostic criteria including 5-20 second latency, torsional upbeating nystagmus toward the affected ear, and symptoms resolving within 60 seconds 13, 14
For patients with acute vestibular syndrome, the HINTS examination (Head Impulse, Nystagmus, Test of Skew) has 100% sensitivity for detecting stroke when performed by trained practitioners 13, 14

The American Academy of Otolaryngology-Head and Neck Surgery suggests performing canalith repositioning procedures (Epley maneuver) for BPPV, with a 90-98% success rate 13, 14
For heart failure patients with dizziness, the European Society of Cardiology recommends evaluating for other causes of dizziness, as it is unlikely related to heart failure medications, and considering diuretic reduction if no signs of congestion 15

Patients with BPPV should be counseled about the risk of recurrence, with a 10-18% risk at one year and up to 36% long-term, and the importance of fall prevention, particularly in elderly patients 13, 14