From the Guidelines
The initial approach to a patient presenting with dizziness should begin with a careful history to distinguish between vertigo, lightheadedness, disequilibrium, or presyncope, and a targeted physical examination including vital signs, orthostatic blood pressure measurements, and neurological examination.
Key Components of the Initial Approach
- Determine the onset, duration, triggers, associated symptoms, and exacerbating factors of the dizziness
- Perform a Dix-Hallpike maneuver for benign paroxysmal positional vertigo (BPPV) and assess for nystagmus
- Consider basic laboratory tests such as complete blood count, electrolytes, glucose, and thyroid function tests
- For acute severe dizziness, consider symptomatic treatment with antiemetics like ondansetron 4-8mg or antihistamines like meclizine 12.5-25mg every 4-6 hours, and vestibular suppressants like diazepam 2-5mg for short-term use 1.
Importance of Accurate Diagnosis
Accurate diagnosis is crucial to differentiate between common causes of dizziness, such as peripheral vestibular disorders (BPPV, vestibular neuritis), central nervous system disorders, cardiovascular issues, metabolic disturbances, medication side effects, or psychological factors, allowing for appropriate management of this potentially debilitating symptom 1.
Recent Guidelines and Recommendations
Recent guidelines recommend against routine radiographic imaging and vestibular testing in patients who meet diagnostic criteria for BPPV, unless additional signs or symptoms are present that warrant further evaluation 1.
Clinical Decision-Making
Clinical decision-making should prioritize a thorough history and physical examination, with selective use of diagnostic tests and treatments based on the individual patient's presentation and risk factors 1.
From the FDA Drug Label
Meclizine hydrochloride is indicated for the treatment of vertigo associated with diseases affecting the vestibular system in adults.
The initial approach to a patient presenting with dizziness is to determine if it is associated with vertigo, as meclizine is specifically indicated for the treatment of vertigo.
- If the patient's dizziness is associated with vertigo, meclizine may be considered as a treatment option.
- However, if the dizziness is not associated with vertigo, the use of meclizine is not directly supported by the FDA drug label 2, 2, 2.
From the Research
Initial Approach to Dizziness
The initial approach to a patient presenting with dizziness involves a thorough history and physical examination to determine the underlying cause of the symptom.
- The patient's history should focus on the timing and triggers of the dizziness, as well as any associated symptoms 3, 4.
- The physical examination should include orthostatic blood pressure measurement, a full cardiac and neurologic examination, assessment for nystagmus, and the Dix-Hallpike maneuver 3.
- The HINTS (head-impulse, nystagmus, test of skew) examination can help distinguish peripheral from central etiologies of dizziness 3.
Diagnostic Categories
Dizziness can be divided into several diagnostic categories, including:
- Acute vestibular syndrome, where bedside physical examination differentiates vestibular neuritis from stroke 4
- Spontaneous episodic vestibular syndrome, where associated symptoms help differentiate vestibular migraine from transient ischemic attack 4
- Triggered episodic vestibular syndrome, where the Dix-Hallpike and supine roll test help differentiate benign paroxysmal positional vertigo from posterior fossa structural lesions 4
Treatment
Treatment of dizziness depends on the underlying cause, and may include:
- Canalith repositioning procedure (e.g., Epley maneuver) for benign paroxysmal positional vertigo 3
- Salt restriction and diuretics for Meniere disease 3
- Vestibular suppressant medications and vestibular rehabilitation for vestibular neuritis 3
Laboratory Testing and Imaging
Laboratory testing and imaging are not required and are usually not helpful in the evaluation of dizziness, unless a specific underlying cause is suspected 3, 5, 6.