Initial Management of Dizziness
The initial steps to manage dizziness should include identifying the type of dizziness, performing targeted physical examination maneuvers, and implementing specific interventions based on the underlying cause. 1
Step 1: Categorize the Type of Dizziness
- Vertigo: Spinning sensation (rotational)
- Presyncope: Feeling of impending faint/lightheadedness
- Disequilibrium: Unsteadiness/imbalance
- Lightheadedness: Vague sensation of disconnection
Step 2: Perform Targeted Physical Examination
For vertigo symptoms:
- HINTS examination (Head Impulse, Nystagmus, Test of Skew) - 92.9% sensitivity and 83.4% specificity for central causes 1
- Dix-Hallpike maneuver for posterior canal BPPV
- Supine roll test for horizontal canal BPPV
For presyncope:
- Orthostatic blood pressure measurement
- Cardiac examination
For all patients:
- Neurological examination to assess for focal deficits
Step 3: Implement Immediate Interventions
For Vertigo (especially BPPV)
- Canalith repositioning procedures - 80-96% success rate with 1-3 treatments 1:
- Epley maneuver (90.7% success rate)
- Gufoni maneuver (93% success rate for geotropic type)
- Barbecue roll/Lempert maneuver (75-90% effectiveness for lateral canal BPPV)
For Medication-Related Dizziness
- Review and consider adjusting medications that may cause dizziness
For Symptomatic Relief
- Vestibular suppressants (short-term use only, <1 week):
Step 4: Patient Education and Lifestyle Modifications
- Keep a daily symptom journal to track triggers and patterns 1
- Avoid triggers (if identified)
- Take precautions to prevent falls
- Regular physical activity to improve balance and coordination 1
- For Ménière's disease, consider sodium restriction (ideally <1500-2300 mg/day) 3
Step 5: Consider Vestibular Rehabilitation
- Especially beneficial for chronic dizziness or after acute vertigo resolves
- Less effective than repositioning maneuvers for BPPV but helpful for residual imbalance 1
Red Flags Requiring Urgent Evaluation
- Abnormal HINTS examination
- Neurological deficits
- First episode of severe vertigo in elderly or those with vascular risk factors
- Atypical presentation or treatment failure 1
Follow-up Recommendations
- Reassess within 1 month to document resolution or persistence of symptoms 1
- Educate about potential for recurrence (approximately 36%) 1
- If symptoms persist, consider referral to specialist and further diagnostic testing
Common Pitfalls to Avoid
- Prolonged use of vestibular suppressants can interfere with central compensation 1
- Failure to recognize serious central causes of dizziness (stroke accounts for 3-7% of vertigo cases) 4
- Inadequate patient education about safety concerns and recurrence risk
- Overlooking psychological factors that can exacerbate and perpetuate dizziness 5