How do you evaluate and manage vertigo (dizziness) on a video visit?

From the Guidelines

Evaluating and managing vertigo during a video visit requires a systematic approach focusing on history, observation, and guided examination, prioritizing the identification of red flags and the differentiation between peripheral and central causes of vertigo, as outlined in the clinical practice guideline for Ménière's disease 1.

Key Components of Evaluation

• Begin by asking the patient to describe their dizziness in detail, distinguishing between true vertigo (spinning sensation) versus lightheadedness or imbalance.
• Inquire about onset, duration, triggers, associated symptoms like nausea, hearing changes, or neurological symptoms, and any recent illnesses or medications.
• Observe the patient for nystagmus, facial asymmetry, or balance issues.
• Guide them through modified Dix-Hallpike maneuvers if appropriate, having them sit on a bed with someone nearby for safety, as recommended in the clinical practice guideline for benign paroxysmal positional vertigo (BPPV) 1.

Management Strategies

• For benign paroxysmal positional vertigo (BPPV), the most common cause, instruct patients on home Epley maneuvers with video guidance.
• Prescribe symptomatic medications like meclizine 12.5-25mg every 4-6 hours as needed for acute symptoms, or diazepam 2-5mg for severe cases, limiting use to 2-3 days to prevent habituation.
• For vestibular neuritis, consider a methylprednisolone taper starting at 24mg daily for 4 days, then tapering by 4mg every 2 days.
• Schedule in-person follow-up for persistent symptoms, especially with red flags like sudden severe headache, speech changes, or focal weakness, as these may indicate a central cause of vertigo that requires further evaluation and management.

Safety Considerations

• Advise patients to avoid driving while experiencing vertigo and to move slowly when changing positions to minimize the risk of falls and injuries.
• Emphasize the importance of follow-up care to monitor symptoms and adjust treatment as needed, ensuring that patients receive timely and appropriate care for their vertigo.

From the FDA Drug Label

The FDA drug label does not answer the question.

From the Research

Evaluating Vertigo on a Video Visit

To evaluate vertigo on a video visit, several key factors must be considered:

• A careful history is essential to establish whether the vertigo is acute, chronic, or recurrent 2
• The patient's description of the timing and triggers of their symptoms can help guide the diagnosis 3, 4
• Associated symptoms such as ear complaints, tinnitus, or hearing loss can indicate an otologic cause 2
• The physical examination, although limited on a video visit, can still provide important clues, such as assessing for nystagmus or performing a virtual Dix-Hallpike maneuver 5, 3

Distinguishing Peripheral from Central Causes

It is crucial to determine whether the vertigo has a peripheral or central cause:

• Peripheral causes are usually benign and can be treated with specific maneuvers or medications 3, 6
• Central causes often require urgent treatment and may indicate a more serious condition such as a stroke or multiple sclerosis 5, 4
• The HINTS (head-impulse, nystagmus, test of skew) examination can help distinguish peripheral from central etiologies, although this may be challenging on a video visit 3

Management and Treatment

Treatment of vertigo on a video visit depends on the underlying cause:

• Benign paroxysmal positional vertigo (BPPV) can be treated with a canalith repositioning procedure, such as the Epley maneuver, which can be guided virtually 6
• Meniere's disease can be managed with salt restriction and diuretics, and vestibular neuritis can be treated with vestibular suppressant medications and vestibular rehabilitation 3
• It is essential to consider the limitations of a video visit and to refer patients to in-person care when necessary, especially if a central cause is suspected or if the patient's symptoms worsen 5, 4