What is the approach to diagnosing and managing vertigo (dizziness)?

From the Guidelines

The approach to vertigo should prioritize determining its origin as peripheral or central, with a focus on Benign Paroxysmal Positional Vertigo (BPPV) diagnosis using the Dix-Hallpike maneuver, as recommended by the clinical practice guideline update 1. When diagnosing vertigo, it is crucial to differentiate between peripheral and central causes. For peripheral vertigo, which is the most common type, the initial step should involve diagnosing BPPV using the Dix-Hallpike maneuver, as outlined in the guideline update 1. This maneuver is performed by bringing the patient from an upright to a supine position with the head turned 45° to 1 side and neck extended 20° with the affected ear down.

Key Considerations

• Diagnosis: The diagnosis of posterior semicircular canal BPPV should be made when vertigo associated with torsional, upbeating nystagmus is provoked by the Dix-Hallpike maneuver, as stated in the guideline 1.
• Treatment: Clinicians should treat patients with posterior canal BPPV with a canalith repositioning procedure, as strongly recommended by the guideline update 1.
• Patient Education: Patient education is crucial and should include discussions on the impact of BPPV on daily life, diagnosis, treatment options, and the risk of recurrence, as emphasized in the supporting text 1.
• Follow-up: Patients should be reassessed within 1 month after an initial period of observation or treatment to document resolution or persistence of symptoms, as recommended by the guideline 1.

Management Strategies

• For BPPV, the canalith repositioning procedure (Epley maneuver) is the recommended initial treatment, according to the guideline update 1.
• Vestibular rehabilitation exercises may be beneficial for promoting adaptation in patients with vertigo, including those with BPPV.
• Central vertigo requires immediate neurological evaluation due to the potential for serious underlying conditions such as stroke.
• Red flags including new headache, neurological deficits, or inability to walk necessitate urgent medical attention.

Additional Considerations

• The risk of falls associated with BPPV, particularly in the elderly, should be addressed through patient counseling on home safety and activity restrictions, as discussed in the supporting text 1.
• Patients should be educated on the importance of follow-up and the potential for recurrence of BPPV, prompting earlier recognition and management of recurrent symptoms.

From the FDA Drug Label

MECLIZINE HYDROCHLORIDE tablets, for oral use Initial U. S. Approval: 1957 INDICATIONS AND USAGE Meclizine hydrochloride tablets are indicated for the treatment of vertigo associated with diseases affecting the vestibular system in adults (1).

The approach to vertigo is to treat it with meclizine hydrochloride tablets, which are indicated for the treatment of vertigo associated with diseases affecting the vestibular system in adults.

• The recommended dosage is 25 mg to 100 mg daily, in divided doses 2.
• Key considerations for treatment include potential drowsiness and anticholinergic action, which should be taken into account when prescribing the medication.

From the Research

Vertigo Approach

The approach to vertigo involves evaluating and managing the condition based on its underlying cause.

• The Epley maneuver is considered the primary treatment for benign paroxysmal positional vertigo (BPPV) 3, 4, 5, 6, 7.
• Anti-vertigo medications such as betahistine and dimenhydrinate can be effective in reducing residual symptoms of BPPV 3.
• The HINTS (head-impulse, nystagmus, test of skew) examination can help distinguish peripheral from central etiologies of vertigo 6.
• Laboratory testing and imaging are not required and are usually not helpful in evaluating vertigo 6.

Treatment Options

Treatment options for vertigo depend on the underlying cause.

• Benign paroxysmal positional vertigo can be treated with a canalith repositioning procedure (e.g., Epley maneuver) 4, 5, 6, 7.
• Meniere disease can be treated with salt restriction and diuretics 6.
• Vestibular neuritis can be treated with vestibular suppressant medications and vestibular rehabilitation 6.
• The Epley maneuver is more effective than vestibular rehabilitation at 1-week follow-up in treating posterior benign paroxysmal positional vertigo (p-BPPV) 7.

Evaluation

Evaluation of vertigo focuses on determining whether the etiology is peripheral or central.

• Peripheral etiologies are usually benign, while central etiologies often require urgent treatment 6.
• The physical examination includes orthostatic blood pressure measurement, a full cardiac and neurologic examination, assessment for nystagmus, and the Dix-Hallpike maneuver 6.
• Patients with episodic vertigo triggered by head motion may have BPPV, while those with vertigo and unilateral hearing loss may have Meniere disease 6.