From the Guidelines
For a patient experiencing dizzy spells during ambulation, I strongly recommend bedside repositioning exercises, such as the Dix-Hallpike test or supine roll test, to guide the crystals back to their original location in the inner ear, as this approach has a high success rate of around 80% with only 1-3 treatments 1. This approach is based on the most recent and highest quality study, which prioritizes the patient's morbidity, mortality, and quality of life as the outcome. The patient should be advised to sit or lie down when dizziness occurs, rise slowly from sitting or lying positions, and use assistive devices like canes or walkers if needed. A thorough evaluation should be conducted to determine the underlying cause, including orthostatic vital signs, neurological examination, and possibly vestibular testing. Vestibular rehabilitation exercises may also be beneficial in the treatment of BPPV, as stated in the clinical practice guideline: benign paroxysmal positional vertigo (update) executive summary 1. Some key points to consider in the management of BPPV include:
- Ensuring patient safety by advising them to avoid sudden movements and eliminate potential hazards in their living environment to prevent falls
- Maintaining adequate hydration
- Considering the use of medications such as meclizine or betahistine for vertigo, if necessary
- Referring the patient to a health professional, such as a medical provider, audiologist, or therapist, who can perform the bedside repositioning exercises, especially if the patient has severe disabling symptoms or is a senior with a history of past falls or fear of falling. The goal of the management approach is to improve the patient's mobility and quality of life while preventing falls, by targeting the underlying mechanism of dizziness, whether it's related to vestibular dysfunction or other causes.
From the Research
Management and Treatment of Dizziness
- The management and treatment of dizziness depend on the etiology of the symptoms 2, 3.
- A physical examination, including orthostatic blood pressure measurement, a full cardiac and neurologic examination, assessment for nystagmus, the Dix-Hallpike maneuver, and the HINTS examination, can help determine the cause of dizziness 2, 3.
- Laboratory testing and imaging are usually not required but can be helpful in some cases 2, 3.
Treatment Options
- Canalith repositioning procedures, such as the Epley maneuver, are effective in treating benign paroxysmal positional vertigo 2, 3.
- Vestibular rehabilitation is helpful in treating many peripheral and central etiologies of dizziness 2.
- Pharmacologic intervention is limited, as it can affect the central nervous system's ability to compensate for dizziness 2.
- Fludrocortisone, a mineralocorticoid, can be used to treat orthostatic hypotension, but its effectiveness and safety are uncertain 4, 5.
- Midodrine, an α-1 adrenergic agonist, is also used to treat orthostatic hypotension, and its safety and effectiveness compared to fludrocortisone are being studied 4, 5, 6.
Orthostatic Hypotension Treatment
- Fludrocortisone and midodrine are considered first-line pharmacologic treatments for orthostatic hypotension 5, 6.
- However, the persistence of treatment with these medications is often short, and further research is needed to determine the causes of this low persistence 6.
- The choice of treatment for orthostatic hypotension depends on the individual patient's condition and medical history 4, 5.