What is the approach for managing dizziness (vertigo)?

Management Approach for Dizziness (Vertigo)

The first-line treatment for benign paroxysmal positional vertigo (BPPV), the most common cause of vertigo, is canalith repositioning procedures (CRPs) such as the Epley maneuver, which have an 80-90% success rate, rather than vestibular suppressant medications. 1

Diagnostic Approach

1. Determine timing and triggers:

   • Episodic vs. continuous
   • Position-triggered vs. spontaneous
   • Associated symptoms (hearing loss, tinnitus, neurological symptoms)

2. Distinguish peripheral from central causes:

   • HINTS examination (Head-Impulse, Nystagmus, Test of Skew) - more sensitive than early MRI for detecting stroke (100% vs 46%) 1
   • Dix-Hallpike maneuver - essential for diagnosing BPPV 2, 1

3. Key differentiating features:

   • Peripheral vertigo: Sudden onset, rotational vertigo, hearing symptoms, position-provoked, nystagmus that suppresses with visual fixation 1
   • Central vertigo: Gradual onset, persistent symptoms, neurological signs, nystagmus that doesn't suppress with fixation 1

Treatment Algorithm

1. For BPPV (most common cause):

• First-line: Canalith repositioning procedures (Epley maneuver) 2, 1
• Success rate: 80-90% for posterior canal BPPV 1
• Counsel patients about recurrence risk (5-13.5% at 6 months, 10-18% at 1 year, up to 36% long-term) 2

2. For vestibular neuritis/labyrinthitis:

• Short-term vestibular suppressants for symptom relief
• Vestibular rehabilitation exercises

3. For Menière's disease:

• Salt restriction and diuretics
• For refractory cases: intratympanic dexamethasone or gentamicin 1

4. For vestibular migraine:

• Migraine prophylaxis
• Trigger avoidance
• Vestibular rehabilitation

Medication Considerations

• Avoid routine use of vestibular suppressants for BPPV as they:

  • May interfere with vestibular compensation 1
  • Are less effective than repositioning maneuvers 1

• If medications are needed for temporary symptom relief:

  • Meclizine: 25-100 mg daily in divided doses 3
  • Caution: May cause drowsiness, anticholinergic effects 3
  • Contraindication: Hypersensitivity to meclizine 3

• For nausea/vomiting:

  • Prokinetic antiemetics (domperidone, metoclopramide) may be useful adjuncts without significantly interfering with vestibular compensation 1

Special Considerations

• Fall risk: Counsel patients about increased fall risk, especially in the elderly 2, 1

  • Assess home safety
  • Consider activity restrictions until symptoms resolve
  • Consider home supervision for elderly/frail patients

• Medication interactions:

  • Avoid combining meclizine with other CNS depressants including alcohol 3
  • Be aware of potential interactions with CYP2D6 inhibitors 3

• Elderly patients:

  • Require lower medication doses
  • Benefit particularly from vestibular rehabilitation 1
  • Higher risk of falls

• Recurrence education:

  • Inform patients about the possibility of recurrence (especially with BPPV)
  • Teach early recognition signs
  • Emphasize importance of follow-up 2

Common Pitfalls to Avoid

1. Overreliance on imaging: Physical examination tests like HINTS and Dix-Hallpike are more valuable for initial diagnosis than routine imaging 1, 4

2. Prolonged use of vestibular suppressants: Can delay central compensation and recovery 1

3. Missing central causes: Always consider stroke in acute, severe vertigo, especially with neurological symptoms 1, 5

4. Inadequate follow-up: Patients should be monitored for symptom resolution and recurrence 2

5. Overlooking medication causes: Many medications can cause dizziness as an adverse effect, particularly aminoglycosides, cycloserine, and certain anticonvulsants 1