What is the appropriate workup and management for a patient presenting with positional lightheadedness?

From the Guidelines

The appropriate workup and management for a patient presenting with positional lightheadedness should start with a thorough history and physical examination, focusing on identifying benign paroxysmal positional vertigo (BPPV) and other potential causes, with the Dix-Hallpike maneuver being a key diagnostic tool, as recommended by the 2017 clinical practice guideline on BPPV 1. The workup should include a review of the patient's medication list, physical examination, and specific tests such as the Dix-Hallpike (positional) testing and supine roll test to assess for lateral semicircular canal BPPV, as outlined in the guideline 1. Key aspects of the history and physical examination include:

• Identifying symptoms consistent with BPPV, such as brief episodes of vertigo triggered by specific head movements
• Assessing for signs and symptoms inconsistent with BPPV that may warrant further evaluation, such as neurological deficits or severe hearing loss
• Evaluating for modifying factors that may impact management, including impaired mobility or balance, central nervous system disorders, lack of home support, and increased risk for falling, as recommended in the guideline 1 Initial management for BPPV should include a canalith repositioning procedure, such as the Epley maneuver, which is a strong recommendation in the guideline 1. Postprocedural postural restrictions after canalith repositioning procedure for posterior canal BPPV are not recommended, as stated in the guideline 1. For patients with persistent symptoms, vestibular rehabilitation therapy may be beneficial, as suggested in the guideline 1. Laboratory tests and neuroimaging should be reserved for patients with signs and symptoms inconsistent with BPPV or when central causes are suspected, as recommended in the guideline 1. Regular follow-up is essential to assess the resolution or persistence of symptoms and to evaluate the need for further treatment or referral, as recommended in the guideline 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 (1). The appropriate workup for a patient presenting with positional lightheadedness may involve evaluating the vestibular system, as meclizine is used to treat vertigo associated with diseases affecting this system 2. The management of positional lightheadedness may include the use of meclizine, as it is indicated for the treatment of vertigo associated with diseases affecting the vestibular system in adults 2. Key points to consider in management:

• Evaluate the patient's vestibular system
• Consider meclizine for treatment of vertigo associated with vestibular system diseases However, the provided drug label does not directly address the workup and management of positional lightheadedness, only vertigo associated with vestibular system diseases.

From the Research

Workup for Positional Lightheadedness

• The workup for positional lightheadedness, particularly in cases of benign paroxysmal positional vertigo (BPPV), typically involves a bedside test known as the Dix-Hallpike test 3, 4, 5.
• This test is used to diagnose BPPV by eliciting vertigo and nystagmus in response to specific head movements.
• The Dix-Hallpike test is a crucial component of the workup, as it helps to confirm the diagnosis of BPPV and guides further management.

Management of Positional Lightheadedness

• The most efficient management of BPPV is to perform the Epley maneuver, a bedside positional maneuver that helps to reposition the calcium particles in the inner ear 3, 4, 6, 5.
• The Epley maneuver has been shown to be highly effective in resolving vertigo symptoms, with success rates ranging from 90% to 96% after one or two treatments 6.
• The maneuver is generally safe, with few adverse effects reported, although some patients may experience nausea or be unable to tolerate the maneuver due to cervical spine problems 4, 7.
• For patients with cervical spine problems, a modified particle repositioning maneuver may be used as an alternative to the Epley maneuver, which has been shown to be effective and safe in these cases 7.

Key Considerations

• The Epley maneuver is recommended by specialty guidelines for the management of BPPV, yet it is frequently underutilized in the emergency department (ED) 5.
• Emergency clinicians should become familiar with performing the Epley maneuver for BPPV, as it is a simple and effective treatment that can improve patient outcomes and reduce the need for further testing and treatment 3, 5.
• Further studies are needed on ED implementation and clinician education of the Epley maneuver to improve its use in clinical practice 5.