From the Guidelines
Treatment for vasovagal dizziness should primarily involve midodrine, as it is associated with a 43% reduction in syncope recurrence, according to the 2017 ACC/AHA/HRS guideline for the evaluation and management of patients with syncope 1. When experiencing vasovagal dizziness, immediate interventions such as lying down and elevating the legs above heart level can help improve blood flow to the brain. For long-term prevention, the following strategies can be employed:
- Increasing daily fluid intake to 2-3 liters and salt consumption, unless contraindicated by other health conditions 1
- Wearing compression stockings to prevent blood pooling in the legs
- Avoiding known triggers such as prolonged standing, hot environments, or the sight of blood
- Using physical counterpressure maneuvers like leg crossing with muscle tensing or hand gripping to abort an episode when warning symptoms appear 1 Medications may be prescribed in severe cases, including:
- Midodrine (ProAmatine) 5-10 mg three times daily to constrict blood vessels, which is reasonable in patients with recurrent VVS with no history of hypertension, heart failure, or urinary retention 1
- Fludrocortisone (Florinef) 0.1-0.2 mg daily to increase blood volume, which might be reasonable for patients with recurrent VVS and inadequate response to salt and fluid intake, unless contraindicated 1
- Beta-blockers like metoprolol 25-100 mg daily to regulate heart rate, which might be reasonable in patients 42 years of age or older with recurrent VVS 1 These treatments work by addressing the underlying mechanism of vasovagal syncope—an inappropriate reflex causing blood vessel dilation and slowed heart rate that reduces blood flow to the brain. For recurrent, severe cases, other treatments like tilt-table training or pacemaker implantation might be considered after other treatments have failed.
From the Research
Treatment Options for Vasovagal Dizziness
- Conservative management is often sufficient, with patients encouraged to increase fluid and salt intake, unless contraindicated 2
- Physical counterpressure maneuvers are recommended for all patients 2
- Midodrine is considered first-line therapy for patients with frequent presyncope or syncope, or those with brief or no prodromes 2, 3
Pharmacological Therapies
- Beta-blockers, serotonin-specific reuptake inhibitors, and fludrocortisone may be considered in certain cases, although their use is not universally recommended 2, 4, 3
- Midodrine is the only drug proven to prevent vasovagal syncope recurrence 3
- Fludrocortisone is being investigated for its potential benefits in preventing vasovagal syncope 3
Alternative Therapies
- Orthostatic training exercises may be effective in improving symptoms in younger, highly motivated patients 3
- Tilt training has shown promise in preventing vasovagal syncope 5
- Implantation of a permanent pacemaker may be considered a last resort in highly refractory cases 3, 5