TL;DR: A brain MRI is not always necessary before vestibular physical therapy for vertigo. When symptoms are consistent with BPPV and no concerning signs are present, clinical evaluation may be appropriate before imaging.
A patient experiencing vertigo recently contacted me after a family member recommended my services by word of mouth.
As I do with all new potential patients, I asked him to complete my screening questions before scheduling. This allows me to review each person’s symptoms and history to determine whether vestibular physical therapy appears appropriate for their current needs.
His answers sounded consistent with classic BPPV symptoms, including positional vertigo. He was able to walk independently, did not report hearing loss, and did not describe any obvious red flags during the screening process.
Based on the information he provided, he appeared to be an appropriate candidate for a vestibular physical therapy evaluation. He scheduled an appointment, and we were all set.
However, he later canceled because he wanted to have a brain MRI before beginning physical therapy.
This situation brings up an important question: Is a brain MRI always necessary before seeing a vestibular physical therapist for vertigo?
Is a Brain MRI Always Necessary Before Vestibular Physical Therapy?
When a patient’s symptoms sound consistent with BPPV and there are no signs or symptoms that would warrant imaging, evidence-based clinical guidance supports appropriate evaluation and treatment without routinely obtaining diagnostic imaging first.
The 2017 Clinical Practice Guideline for Benign Paroxysmal Positional Vertigo states that clinicians should not obtain radiographic imaging for a patient who meets the diagnostic criteria for BPPV unless the patient has additional signs or symptoms that are inconsistent with BPPV and warrant further testing.
The guideline was designed in part to improve the accurate and efficient diagnosis of BPPV, reduce unnecessary diagnostic testing, prevent delays in appropriate care, and decrease overall healthcare costs.
In other words, a brain MRI is not automatically required simply because someone is experiencing vertigo.
Can BPPV Be Diagnosed Without a Brain MRI?
Yes. BPPV is a biomechanical problem within the inner ear caused by dislodged and displaced microscopic calcium carbonate crystals. Understanding the biomechanics of BPPV and how it presents in real life can also help explain why the condition is evaluated and treated differently than other neurological causes of dizziness.
A trained vestibular provider evaluates for BPPV using the patient’s history, positional testing, notation of symptoms, and careful observation of involuntary eye movements (nystagmus). If BPPV is identified, it can often be treated successfully with a specific repositioning maneuver during the appointment. BPPV treatment may take a few sessions for a complete resolution, but can often be treated by a vestibular provider without a brain MRI or neurology consultation.
It is true that other “central” neurological causes of dizziness typically require a brain MRI to diagnose. However, a brain MRI does not diagnose any loose crystals in the inner ear or tell a provider which repositioning maneuver for BPPV treatment is needed.
In fact, a normal brain MRI result is often a source of confusion for family members of my patients with BPPV related vertigo. The family member may be confused or surprised when I show them video footage with results of my vestibular exam using infrared video oculography (camera) goggles because the brain MRI results were “normal.” This is especially common if the patient also presents with anxiety, because their doctors and family members may attribute all their discomfort to anxiety-related dizziness if the brain MRI result is normal.
The Bottom Line: Choosing to wait for brain imaging that has not been recommended may delay the vestibular evaluation and appropriate care. In some cases, the brain MRI may not be necessary at all.
When Is Further Medical Testing Appropriate for Vertigo?
Not every case of dizziness or vertigo is caused by BPPV. Additional medical evaluation or diagnostic testing may be appropriate when symptoms do not fit the typical pattern of BPPV or when concerning signs are present.
This is one reason I use screening questions for every new potential patient. The screening process helps me determine whether my services appear appropriate or whether the person may need a different type of medical care first.
Screening is not a diagnosis, however. A diagnosis of BPPV requires an appropriate clinical evaluation, typically with infrared video oculography goggles to record videos of nystagmus during BPPV testing.
Keep in mind that all vestibular health care providers are trained to identify “red flags” that may show up during a clinical exam. Red flags during a vestibular exam are certain neurological signs and patterns of nystagmus that indicate a brain MRI is needed in that case.
If your physician or vestibular provider has ordered a brain MRI, referred you to another specialty provider, or recommended other diagnostic testing like a hearing test, neck MRI, or vestibular function testing, I encourage you to follow through with those medical recommendations.
The decision about imaging should be based on your individual symptoms, health history, clinical findings, presence or absence of any red flags in your case, and your healthcare provider’s clinical judgment.
Should You See a Vestibular Physical Therapist Before an MRI?
If your symptoms sound like BPPV and you have not been advised by your doctor to complete brain MRI imaging first, you may not need to postpone a vestibular physical therapy evaluation – even if you are independently pursuing a brain MRI for peace of mind.
A vestibular physical therapist can assess your symptoms, determine whether your presentation is consistent with BPPV, and treat you for BPPV without any brain imaging.
The vestibular physical therapist will refer you for additional medical evaluation if the exam findings are not consistent with a typical inner-ear condition like BPPV.
If the vestibular physical therapist thinks a brain MRI is needed after completing your clinical oculomotor and vestibular evaluation, they will notify you and your doctor of the red flags that appeared on the vestibular exam and the reason for the recommendation to get a brain MRI.
The Bottom Line: Prompt evaluation by a vestibular healthcare professional may help you receive appropriate care sooner while avoiding unnecessary testing and additional healthcare expenses. You may be able to get BPPV treatment for a full resolution of your vertigo before a brain MRI can even be scheduled!
If you are not sure if you need a brain MRI for vertigo, talk to your doctor.
If you are experiencing dizziness or vertigo and would like to find out whether my specialized services may be appropriate for you, I invite you to request a consultation. I provide top-shelf concierge personalized vestibular physical therapy care at my private practice in Vista, California, and offer house calls within the greater San Diego area for an additional fee. Patients travel from across the USA and many foreign countries to work with me, so I often see the most complex and challenging cases.
Reference
Bhattacharyya N, Gubbels SP, Schwartz SR, et al. Clinical Practice Guideline: Benign Paroxysmal Positional Vertigo (Update). Otolaryngology–Head and Neck Surgery. 2017;156(3_suppl):S1-S47.
Frequently Asked Questions
Do I need a brain MRI for BPPV?
Not always. When a patient’s symptoms and clinical findings are consistent with BPPV and there are no additional signs or symptoms suggesting another condition, routine diagnostic imaging is not generally recommended solely to diagnose BPPV.
Can I see a vestibular physical therapist before getting an MRI?
In some cases, yes. If symptoms are consistent with BPPV and there are no concerning signs requiring further medical evaluation, a vestibular physical therapist may be able to evaluate and treat the condition without waiting for an MRI. Your individual healthcare provider’s recommendations should always be considered.
When is an MRI appropriate for vertigo?
An MRI or other medical testing may be appropriate when symptoms do not fit the typical pattern of BPPV or when additional signs or symptoms raise concern for another condition. The decision to obtain imaging should be based on the individual’s symptoms, history, examination findings, and healthcare provider’s clinical judgment.
Disclaimer
This blog is provided for informational and educational purposes only. The content and any comments by Dr. Kim Bell, DPT are not intended to be a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition. The details of any case mentioned in this post represent a typical patient that Dr. Bell might see and do not describe the circumstances of a specific individual.
