Residency · Residency · Family Medicine

Dizziness and Vertigo: A Systematic Approach

Overview

Dizziness is one of the most common complaints in primary care, accounting for approximately 5% of walk-in clinic visits. A systematic approach using the TiTrATE framework (Timing, Triggers, and Associated symptoms) can efficiently narrow the differential and guide appropriate management while avoiding overreliance on imaging and vestibular suppressants.

Defining Dizziness Subtypes

The traditional approach of asking patients to categorize their dizziness as vertigo, lightheadedness, disequilibrium, or presyncope has proven unreliable because patients inconsistently use these terms. The modern TiTrATE approach classifies dizziness by timing, triggers, and associated symptoms, yielding four clinically useful categories. Episodic triggered dizziness includes BPPV and orthostatic hypotension. Episodic spontaneous dizziness encompasses vestibular migraine, Meniere disease, and panic or anxiety. Acute prolonged or continuous dizziness points to vestibular neuritis or stroke. Chronic persistent dizziness suggests persistent postural-perceptual dizziness, bilateral vestibulopathy, or medication effects.

Benign Paroxysmal Positional Vertigo (BPPV)

Pathophysiology

BPPV results from displaced otoconia, which are calcium carbonate crystals, migrating into the semicircular canals. The posterior canal is affected in 80 to 90% of cases. Brief episodes of vertigo are triggered by head position changes such as rolling over in bed, looking up, or bending forward.

Diagnosis

The Dix-Hallpike test is the gold standard for diagnosing posterior canal BPPV. The patient is seated with the head turned 45 degrees to one side and rapidly laid supine with the head hanging 20 degrees below the table. A positive test produces upbeating torsional nystagmus with a 2 to 5 second latency, lasting less than 60 seconds, and the response is fatigable. Both sides should be tested, and the positive side identifies the affected ear. The supine roll test is used for horizontal canal BPPV, which produces either geotropic or apogeotropic nystagmus.

Treatment

The Epley maneuver, also known as canalith repositioning, is the treatment of choice for posterior canal BPPV. It has a success rate of approximately 80% with a single treatment, rising above 90% with repetition. The maneuver can be performed in the office and taught to patients for home use as a modified Epley or Brandt-Daroff exercise. Meclizine and other vestibular suppressants have no role in BPPV treatment because the episodes are too brief for these medications to be effective, and they only cause unnecessary sedation. Post-treatment positional restrictions are not necessary, and the maneuver should simply be repeated if symptoms recur. The annual recurrence rate is 15 to 20%.

Vestibular Neuritis (Acute Vestibular Syndrome)

Presentation

Vestibular neuritis presents as acute onset of severe continuous vertigo accompanied by nausea, vomiting, and gait instability, lasting days to weeks with gradual improvement. It often follows a viral illness. The absence of hearing loss distinguishes vestibular neuritis from labyrinthitis, which includes auditory symptoms.

HINTS Exam (Head Impulse, Nystagmus, Test of Skew)

The HINTS exam is used to differentiate peripheral causes (vestibular neuritis) from central causes (stroke) in patients presenting with acute vestibular syndrome. A peripheral or benign pattern consists of a positive head impulse test with a corrective saccade toward the affected side, direction-fixed horizontal nystagmus, and no skew deviation. A central or dangerous pattern shows a normal head impulse test, direction-changing or vertical nystagmus, and the presence of skew deviation. When performed by a trained examiner, the HINTS exam has a sensitivity exceeding 96% for stroke detection, outperforming MRI in the first 24 to 48 hours. Importantly, the HINTS exam should only be applied to patients with acute continuous vertigo and spontaneous nystagmus; it is not valid for episodic dizziness.

Treatment

Vestibular suppressants should be used for a maximum of 48 to 72 hours: meclizine at 25 mg three times daily, dimenhydrinate at 50 mg every 6 hours, or ondansetron for nausea alone. Prolonged use of vestibular suppressants delays central compensation and prolongs recovery. Early vestibular rehabilitation is the most important intervention, as exercises promote the central compensatory mechanisms that drive recovery. Corticosteroids with a methylprednisolone taper may improve vestibular recovery if started within 72 hours, though the evidence remains limited and this approach is considered controversial. Most patients recover within weeks to months, but 10 to 15% develop persistent symptoms.

Vestibular Migraine

Diagnosis (ICHD-3/Barany Society Criteria)

Vestibular migraine requires five or more episodes of vestibular symptoms (vertigo, positional vertigo, or dizziness with head movement) lasting 5 minutes to 72 hours. The patient must have a current or past history of migraine with or without aura. At least 50% of episodes must include at least one migrainous feature such as headache, photophobia, phonophobia, or visual aura. The condition must not be better accounted for by another vestibular or ICHD diagnosis.

Key Features

Vestibular migraine is the most common cause of recurrent spontaneous vertigo. Episodes may occur with or without headache, and vertigo can be the sole manifestation, which contributes to its frequent misdiagnosis as Meniere disease or BPPV.

Treatment

Acute treatment includes vestibular suppressants and triptans when accompanied by headache. Preventive therapy uses the same medications as standard migraine prevention, including topiramate, venlafaxine, propranolol, and amitriptyline. Lifestyle modifications such as sleep hygiene, trigger avoidance, regular meals, and stress management are important adjuncts.

Meniere Disease

Diagnosis (AAO-HNS 2020 Criteria)

Meniere disease requires two or more episodes of spontaneous vertigo lasting 20 minutes to 12 hours, low-to-mid frequency sensorineural hearing loss documented on audiometry, and aural fullness or tinnitus in the affected ear. The symptoms must not be better accounted for by another diagnosis.

Treatment

Dietary sodium restriction to less than 2 grams per day is the cornerstone of management, as it reduces endolymphatic hydrops. Diuretics such as hydrochlorothiazide or acetazolamide are commonly used despite weak evidence. Betahistine is widely used outside the United States but is not FDA-approved, and the evidence for its efficacy is equivocal. Intratympanic dexamethasone is reserved for refractory vertigo episodes, while intratympanic gentamicin achieves chemical labyrinthectomy for severe refractory cases at the cost of a risk of hearing loss. Vestibular rehabilitation helps with chronic imbalance between episodes, and hearing aids address associated hearing loss.

Orthostatic Hypotension

Orthostatic hypotension is defined as a drop of 20 mmHg or more in systolic blood pressure or 10 mmHg or more in diastolic blood pressure within 3 minutes of standing. Common causes include medications (antihypertensives, alpha-blockers, diuretics, tricyclic antidepressants), dehydration, autonomic neuropathy (as seen in diabetes and Parkinson disease), and adrenal insufficiency. Treatment involves medication review and adjustment, compression stockings, increased salt and fluid intake, and pharmacologic agents such as midodrine, fludrocortisone, and droxidopa.

Persistent Postural-Perceptual Dizziness (PPPD)

PPPD is defined as chronic, persistent non-spinning dizziness or unsteadiness lasting more than 3 months, worsened by upright posture, active or passive motion, and complex visual stimuli. It often develops following an acute vestibular event such as BPPV or vestibular neuritis, or after a panic attack. PPPD is a functional vestibular disorder and should not be confused with malingering. Treatment includes CBT, which is the most effective intervention, SSRIs or SNRIs such as sertraline or venlafaxine, and vestibular rehabilitation.

Central Causes to Exclude

Posterior Circulation Stroke

Posterior circulation stroke should be considered in patients with vascular risk factors such as age, hypertension, diabetes, and atrial fibrillation. Lateral medullary or Wallenberg syndrome presents with vertigo, dysphagia, Horner syndrome, and crossed sensory loss. Cerebellar infarction causes severe ataxia, inability to sit unaided, and vertical or direction-changing nystagmus. The HINTS exam reliably differentiates vestibular neuritis from posterior circulation stroke. CT scan is insensitive for posterior fossa strokes; MRI with diffusion-weighted imaging is required when central pathology is suspected, though MRI itself may be falsely negative in the first 24 to 48 hours.

Other Central Causes

Multiple sclerosis may present with internuclear ophthalmoplegia and other brainstem or cerebellar signs. Cerebellar tumors cause progressive unilateral signs. Chiari malformation characteristically produces downbeat nystagmus with occipital headache worsened by Valsalva maneuver.

Medication-Induced Dizziness

Medication-induced dizziness is extremely common, and the medication list should be reviewed in all patients presenting with dizziness. Common culprits include antihypertensives, anticonvulsants, sedatives and hypnotics, aminoglycoside antibiotics (which cause ototoxicity), opioids, and anticholinergics. In the elderly, dizziness is often multifactorial, resulting from the combination of polypharmacy, orthostatic hypotension, and sensory deficits.

Approach to the Dizzy Patient in Primary Care

Key Questions

Five key questions help organize the evaluation of dizziness. First, is the dizziness episodic or continuous? Second, what triggers it, whether head position, standing, or nothing at all? Third, how long does each episode last, as seconds suggest BPPV, minutes to hours suggest Meniere disease or vestibular migraine, and days suggest vestibular neuritis? Fourth, are there auditory symptoms such as hearing loss or tinnitus, which indicate cochlear involvement? Fifth, are there neurologic symptoms such as focal weakness, diplopia, or dysarthria, which suggest a central cause?

When to Image

Neuroimaging is indicated when central signs are present on the HINTS exam, when new focal neurologic deficits are found, in patients with acute onset and vascular risk factors, or when symptoms are progressive over weeks. Imaging is not indicated for classic BPPV or typical vestibular migraine.

<image>A clinical decision tree for the dizzy patient beginning with timing and trigger classification (episodic triggered, episodic spontaneous, acute continuous, chronic) leading to the most likely diagnosis in each category. Show BPPV in the episodic triggered branch, vestibular migraine and Meniere in episodic spontaneous, vestibular neuritis vs. stroke in acute continuous, and PPPD in chronic. Include key bedside tests (Dix-Hallpike, HINTS) at decision points.</image>

<image>A step-by-step illustrated guide to performing the Dix-Hallpike test and Epley maneuver showing patient and examiner positioning at each step, head rotation angles, expected nystagmus direction for a positive test, hold times at each position, and the sequence of movements for canalith repositioning. Use numbered steps with clear body position diagrams.</image>

<image>The HINTS exam illustrated for differentiating peripheral from central acute vestibular syndrome. Show three panels: (1) Head Impulse Test with corrective saccade (peripheral) vs. normal (central), (2) Nystagmus pattern with direction-fixed (peripheral) vs. direction-changing (central), (3) Test of Skew with no deviation (peripheral) vs. vertical skew deviation (central). Include a summary box indicating that a central pattern warrants urgent neuroimaging.</image>

Clinical Pearls

Meclizine is not appropriate treatment for BPPV; the Epley maneuver is the treatment of choice with over 80% success rate on the first attempt. The HINTS exam, when performed correctly, is more sensitive than MRI for detecting posterior circulation stroke in the first 48 hours. HINTS should only be applied to patients with acute continuous vertigo and spontaneous nystagmus and is not valid for episodic dizziness. Vestibular migraine is the most common cause of recurrent spontaneous vertigo and frequently occurs without headache. Vestibular suppressants such as meclizine and dimenhydrinate should be limited to 48 to 72 hours because prolonged use delays central compensation and prolongs recovery. CT scan is insensitive for posterior fossa strokes, and if a central cause is suspected, MRI with diffusion-weighted imaging is required. Chronic dizziness following a resolved acute vestibular event may represent PPPD and should be treated with vestibular rehabilitation, SSRIs, and CBT rather than repeated imaging. Orthostatic vitals and a thorough medication review should be part of the evaluation of any patient presenting with dizziness, especially in the elderly.

References

• Edlow JA et al. A New Diagnostic Approach to the Adult Patient with Acute Dizziness. J Emerg Med. 2018
• Kattah JC et al. HINTS to Diagnose Stroke in Acute Vestibular Syndrome. Stroke. 2009
• Bhattacharyya N et al. AAO-HNS Clinical Practice Guideline: BPPV. Otolaryngol Head Neck Surg. 2017
• Lempert T et al. Vestibular Migraine: Diagnostic Criteria (Barany Society/IHS). J Vestib Res. 2022
• Staab JP et al. Diagnostic Criteria for PPPD (Barany Society). J Vestib Res. 2017
• Hilton MP, Pinder DK. Epley Maneuver for BPPV. Cochrane Database Syst Rev. 2014

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