What are the guidelines for managing acute onset vertigo (dizziness)?

From the Guidelines

Management of acute onset dizziness should prioritize diagnosing and treating the underlying cause, with a focus on benign paroxysmal positional vertigo (BPPV) diagnosis using the Dix-Hallpike maneuver and treatment with a canalith repositioning procedure, as recommended by the most recent guidelines 1. The diagnosis and management of acute onset dizziness can be complex, involving various peripheral vestibular disorders, central nervous system disorders, or systemic conditions.

Key Considerations

• The Dix-Hallpike maneuver is a crucial diagnostic tool for posterior semicircular canal BPPV, and a supine roll test should be performed if the Dix-Hallpike test is negative and lateral semicircular canal BPPV is suspected 1.
• Clinicians should differentiate BPPV from other causes of imbalance, dizziness, and vertigo, and assess patients for factors that modify management, such as impaired mobility or balance, central nervous system disorders, lack of home support, and increased risk for falling 1.
• Treatment of BPPV should involve a canalith repositioning procedure, such as the Epley maneuver, and patients should be reassessed within 1 month after initial treatment to confirm symptom resolution 1.

Treatment Options

• Vestibular rehabilitation exercises may be offered as an initial treatment for BPPV, and observation with follow-up may be considered for patients with BPPV 1.
• Vestibular suppressant medications, such as antihistamines or benzodiazepines, should not be routinely used to treat BPPV, as they can delay central compensation and are not effective as a primary treatment 1.
• Patients with vestibular neuritis may benefit from a short course of corticosteroids, and emergency evaluation is warranted for dizziness accompanied by neurological deficits, severe headache, or new-onset ataxia 1.

Patient Education

• Patients should be educated regarding the impact of BPPV on their safety, the potential for disease recurrence, and the importance of follow-up, as well as advised to maintain hydration, avoid sudden head movements, and sit or lie down when dizzy 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 FDA drug label does not provide specific guidelines for management of acute onset dizziness.

• The label only mentions the treatment of vertigo associated with diseases affecting the vestibular system in adults 2, 2, 2.
• There is no direct information on the management of acute onset dizziness.

From the Research

Guidelines for Management of Acute Onset Dizziness

• The management of acute onset dizziness involves determining whether the etiology is peripheral or central, as central etiologies often require urgent treatment 3.
• A timing-and-triggers approach can be used to characterize the patient's vestibular symptoms as continuous or episodic, and to guide the evaluation and diagnosis of acute dizziness and vertigo 4, 5.
• The HINTS (head-impulse, nystagmus, test of skew) examination can help distinguish peripheral from central etiologies 3, 5.
• The physical examination includes orthostatic blood pressure measurement, a full cardiac and neurologic examination, assessment for nystagmus, and the Dix-Hallpike maneuver 3, 5, 6.

Diagnosis of Specific Conditions

• Benign paroxysmal positional vertigo (BPPV) can be diagnosed with a Dix-Hallpike maneuver or supine roll test, and typically does not require additional ancillary testing 6.
• Vestibular neuritis can be diagnosed with various diagnostic tests such as the head impulse test, bithermal caloric test, and vestibular-evoked myogenic potential test 7.
• Meniere disease can be suggested by vertigo with unilateral hearing loss 3.

Treatment Options

• Benign paroxysmal positional vertigo can be treated with a canalith repositioning procedure (e.g., Epley maneuver) 3, 6.
• Vestibular neuritis can be treated with symptomatic therapy, specific drug therapy, and vestibular rehabilitation therapy 7.
• Meniere disease can be treated with salt restriction and diuretics 3.