What is the management of vertigo (dizziness)?

From the Guidelines

The management of vertigo (dizziness) involves identifying and treating the underlying cause while providing symptomatic relief, with a strong recommendation for clinicians to diagnose posterior semicircular canal BPPV when vertigo associated with torsional, upbeating nystagmus is provoked by the Dix-Hallpike maneuver, as stated in the clinical practice guideline: benign paroxysmal positional vertigo (update) executive summary 1.

Key Considerations

• Determine the type of dizziness (vertigo, lightheadedness, disequilibrium, or presyncope) through a thorough history and physical examination.
• For benign paroxysmal positional vertigo (BPPV), the Epley maneuver can be performed to reposition displaced otoconia, with a strong recommendation for clinicians to treat patients with posterior canal BPPV with a canalith repositioning procedure 1.
• Vestibular suppressants like meclizine, diazepam, or promethazine can provide short-term symptomatic relief but should be limited to 3-5 days to prevent compensation delay, as they are not recommended for routine treatment of BPPV 1.

Diagnosis and Treatment

• The Dix-Hallpike test should be used to diagnose posterior semicircular canal BPPV, with a strong recommendation for clinicians to diagnose posterior semicircular canal BPPV when vertigo associated with torsional, upbeating nystagmus is provoked by the Dix-Hallpike maneuver 1.
• The supine roll test can be used to diagnose lateral semicircular canal BPPV, with a recommendation for clinicians to perform, or refer to a clinician who can perform, a supine roll test to assess for lateral semicircular canal BPPV if the patient has a history compatible with BPPV and the Dix-Hallpike test exhibits horizontal or no nystagmus 1.
• Clinicians should not obtain radiographic imaging in a patient who meets diagnostic criteria for BPPV in the absence of additional signs and/or symptoms inconsistent with BPPV that warrant imaging, with a recommendation against radiographic testing in patients with BPPV 1.

Patient Education and Safety

• Patients with BPPV should be educated regarding the impact of BPPV on their safety, the potential for disease recurrence, and the importance of follow-up, with a recommendation for clinicians to educate patients regarding the impact of BPPV on their safety 1.
• Patients should be advised to ensure home safety by removing trip hazards, using night lights, and installing grab bars to prevent falls during dizzy episodes.

Additional Considerations

• Vestibular rehabilitation therapy is effective for many causes of chronic dizziness, improving central compensation through specialized exercises.
• For Ménière's disease, a low-salt diet, diuretics, and avoiding caffeine and alcohol can help reduce symptoms.
• Patients with orthostatic hypotension should increase fluid intake, add salt to their diet, wear compression stockings, and rise slowly from lying or sitting positions.

From the FDA Drug Label

MECLIZINE HYDROCHLORIDE tablets, for oral use Initial U. S. Approval: 1957 INDICATIONS AND USAGE Meclizine hydrochloride tablets are indicated for the treatment of vertigo associated with diseases affecting the vestibular system in adults (1). DOSAGE AND ADMINISTRATION Recommended dosage: 25 mg to 100 mg daily, in divided doses (2.1).

The management of vertigo (dizziness) with meclizine hydrochloride tablets is to take 25 mg to 100 mg daily, in divided doses.

• The dosage should be taken as directed by a healthcare professional.
• Meclizine hydrochloride tablets are specifically indicated for the treatment of vertigo associated with diseases affecting the vestibular system in adults 2.

From the Research

Management of Vertigo (Dizziness)

The management of vertigo (dizziness) is dependent on the etiology of the symptoms.

• The treatment for dizziness is dependent on the etiology of the symptoms 3.
• Canalith repositioning procedures (e.g., Epley maneuver) are the most helpful in treating benign paroxysmal positional vertigo 3, 4.
• Vestibular rehabilitation is helpful in treating many peripheral and central etiologies 3, 4.
• Other etiologies of dizziness require specific treatment to address the cause 3, 4.
• Pharmacologic intervention is limited because it often affects the ability of the central nervous system to compensate for dizziness 3.

Diagnosis and Evaluation

• Distinguishing between central and peripheral causes of vertigo can be accomplished reliably through history and examination 5.
• The physical examination may include orthostatic blood pressure measurement, a full cardiac and neurologic examination, assessment for nystagmus, the Dix-Hallpike maneuver (for patients with triggered dizziness), and the HINTS (head-impulse, nystagmus, test of skew) examination when indicated 3, 4.
• Laboratory testing and imaging are usually not required but can be helpful 3, 4.
• A systematic and thorough approach to the dizzy patient will often yield the diagnosis, exclude otologic causes for imbalance, and ultimately set the patient on a proper course of treatment 6.

Common Causes and Symptoms

• Possible causes of dizziness include conflicts between visual and vestibular information, vascular problems, adverse reactions to medication, psychological difficulties, systemic disease, and the effects of aging 7.
• Dizziness is a symptom of a physiological or psychological illness, and therefore management is typically directed toward treatment of the underlying illness 7.
• Episodic vertigo triggered by head motion may be due to benign paroxysmal positional vertigo 4.
• Vertigo with unilateral hearing loss suggests Meniere disease 4.
• Episodic vertigo not associated with any trigger may be a symptom of vestibular neuritis 4.