What is the best approach to manage a 41-year-old male patient with symptoms of dizziness, numbness, and tingling in the face, particularly when changing positions, and who reports improvement after avoiding sun exposure for four days?

From the Guidelines

The best approach for this 41-year-old male with positional dizziness and facial paresthesia who improved with sun avoidance would be to first obtain a complete neurological examination and consider vestibular testing, as orthostatic intolerance and postural tachycardia syndrome (POTS) are potential underlying conditions 1. Given the patient's symptoms of dizziness, numbness, and tingling in the face, particularly when changing positions, and improvement after avoiding sun exposure for four days, it is essential to investigate for photosensitive disorders and autonomic dysfunction.

• Initial management should include:
  • Continued sun avoidance
  • Laboratory tests: complete blood count, metabolic panel, autoimmune markers (ANA, anti-dsDNA), porphyrin levels, and vitamin B12 levels
  • Symptomatic relief with meclizine 25mg every 6-8 hours as needed for dizziness
• If vestibular issues are confirmed, vestibular rehabilitation therapy should be initiated, as it may help improve symptoms and quality of life 1.
• The patient should maintain a symptom diary correlating episodes with sun exposure and position changes to better understand the relationship between these factors and his symptoms.
• The improvement with sun avoidance suggests a photosensitive component to his condition, possibly involving autonomic dysfunction or an autoimmune process affecting the vestibular system or trigeminal nerve, which should be further investigated 1.
• Adequate hydration and gradual position changes may help minimize symptoms while the underlying cause is being determined, as orthostatic intolerance and POTS can be associated with hemodynamic disturbances and symptoms that worsen with standing 1.
• Follow-up should be scheduled within 2-3 weeks to assess response to interventions and review test results, allowing for adjustments to the management plan as needed.

From the FDA Drug Label

Administration of midodrine results in a rise in standing, sitting, and supine systolic and diastolic blood pressure in patients with orthostatic hypotension of various etiologies Standing systolic blood pressure is elevated by approximately 15 to 30 mmHg at 1 hour after a 10 mg dose of midodrine, with some effect persisting for 2 to 3 hours.

The patient's symptoms of dizziness, numbness, and tingling in the face, particularly when changing positions, may be indicative of orthostatic hypotension. Midodrine may be considered as a treatment option to help manage these symptoms by increasing blood pressure. However, it is essential to carefully evaluate the patient's condition and monitor blood pressure regularly to minimize the risk of supine hypertension. The patient should be advised to report any symptoms of supine hypertension immediately and to take their last daily dose of midodrine 3 to 4 hours before bedtime to minimize nighttime supine hypertension 2.

Key considerations for the patient's management include:

• Monitoring blood pressure carefully, especially when midodrine is used concomitantly with other agents that cause vasoconstriction
• Advising the patient to avoid taking their dose if they are to be supine for any length of time
• Assessing renal and hepatic function prior to initiating therapy and subsequently, as appropriate
• Avoiding concomitant use of drugs that increase blood pressure, such as phenylephrine, pseudoephedrine, and ephedrine 2.

From the Research

Diagnostic Approach

• The patient's symptoms of dizziness, numbness, and tingling in the face, particularly when changing positions, suggest a potential vestibular or orthostatic cause 3, 4.
• A thorough physical examination, including orthostatic blood pressure measurement, is essential to evaluate the patient's symptoms 3, 5.
• The patient's improvement after avoiding sun exposure for four days may indicate a possible relationship between environmental factors and their symptoms.

Orthostatic Hypotension

• Orthostatic hypotension is a potential cause of the patient's symptoms, characterized by a fall in blood pressure on standing, leading to dizziness and discomfort 5, 6.
• Treatment of orthostatic hypotension may involve non-pharmacologic interventions, such as carefully managed exercise and scheduled activities, as well as pharmacologic agents like fludrocortisone and midodrine 5, 6.

Vestibular Disorders

• Benign paroxysmal positional vertigo (BPPV) is a common peripheral vestibular disorder that can cause dizziness and vertigo, particularly when changing positions 3, 7.
• The Dix-Hallpike maneuver and supine roll test can help diagnose BPPV, while canalith repositioning procedures, such as the Epley maneuver, can be effective in treating this condition 3, 7.

Laboratory Testing and Imaging

• Laboratory testing and imaging are not always required but can be helpful in evaluating the patient's symptoms, particularly if a central cause is suspected 3, 4.
• Electrolyte levels and orthostatic blood pressure measurements can provide valuable information in diagnosing and managing the patient's condition 5.