From the Guidelines
The approach to a patient with dizziness begins with distinguishing between vertigo, presyncope, disequilibrium, and non-specific dizziness, and a thorough history and physical examination are essential for diagnosis and management. The diagnosis of dizziness can be complex, and it is crucial to consider various causes, including benign paroxysmal positional vertigo (BPPV), Ménière's disease, and central causes.
- A thorough history should focus on onset, duration, triggers, associated symptoms, and medication review.
- Physical examination should include vital signs, orthostatic measurements, neurological assessment, and specialized tests like the Dix-Hallpike maneuver for BPPV.
- For BPPV, the Epley maneuver can be performed immediately for treatment, as recommended by the 2017 clinical practice guideline update 1.
- Acute vestibular neuritis may require symptomatic treatment with antihistamines like meclizine 25mg every 4-6 hours or diazepam 2-5mg every 8 hours for 3-5 days.
- Ménière's disease often responds to low-salt diet, diuretics like hydrochlorothiazide 25mg daily, and avoiding caffeine and alcohol, as described in the 2020 clinical practice guideline on Ménière's disease 1.
- Central causes of dizziness require urgent neuroimaging.
- For chronic dizziness, vestibular rehabilitation therapy is effective, and patients with orthostatic hypotension should increase fluid and salt intake, rise slowly from sitting/lying positions, and may need medication adjustments.
- Careful attention to cardiovascular status is essential as dizziness may indicate cardiac issues, and laboratory tests including CBC, electrolytes, glucose, and thyroid function may identify metabolic causes.
- The multifactorial nature of dizziness often requires addressing multiple contributing factors simultaneously for effective management, and patient education and counseling are crucial for managing the condition and preventing complications, as emphasized in the 2017 clinical practice guideline update on BPPV 1.
From the FDA Drug Label
Meclizine hydrochloride tablets are indicated for the treatment of vertigo associated with diseases affecting the vestibular system in adults. The approach to a patient with dizziness would be to consider vertigo as a possible cause, and meclizine may be indicated for treatment if the dizziness is associated with diseases affecting the vestibular system 2.
- Key considerations:
- Dizziness may be a symptom of various conditions, and a thorough evaluation is necessary to determine the underlying cause.
- Meclizine is specifically indicated for vertigo associated with vestibular system diseases, and its use should be guided by a clear diagnosis. However, the provided drug labels do not directly address the approach to a patient with dizziness in general, but rather focus on the treatment of vertigo.
From the Research
Approach to Patient with Dizziness
The approach to a patient with dizziness involves a thorough evaluation and management plan. Key considerations include:
- Focusing on the timing of events and triggers of dizziness to develop a differential diagnosis 3, 4, 5
- Determining whether the etiology is peripheral or central, as peripheral etiologies are usually benign while central etiologies often require urgent treatment 3, 4
- Performing a physical examination, which may include:
Differential Diagnosis
The differential diagnosis for dizziness is broad and includes:
- Peripheral causes, such as benign paroxysmal positional vertigo (BPPV) and Meniere disease 3, 4
- Central causes, which can be life-threatening and require urgent treatment 3, 6
- Other etiologies, such as vestibular neuritis and presyncope 4, 5
Treatment
Treatment for dizziness depends on the underlying etiology and may include:
- Canalith repositioning procedures (e.g., Epley maneuver) for BPPV 3, 4
- Vestibular rehabilitation for peripheral and central etiologies 3
- Pharmacologic intervention, although this is often limited due to its effects on the central nervous system's ability to compensate for dizziness 3
- Specific treatment for other etiologies, such as salt restriction and diuretics for Meniere disease 4