What are the initial management steps for a patient presenting with dizziness?

Initial Management of Dizziness

The initial management of dizziness should focus on determining whether the cause is peripheral or central, performing appropriate diagnostic maneuvers like the Dix-Hallpike test or HINTS examination, and implementing targeted interventions based on the specific diagnosis. 1

Diagnostic Approach

1. Classify Dizziness by Timing and Triggers

• Acute Vestibular Syndrome: Continuous dizziness lasting days to weeks (vestibular neuritis, labyrinthitis, stroke)
• Triggered Episodic Vestibular Syndrome: Brief episodes triggered by position changes (BPPV)
• Spontaneous Episodic Vestibular Syndrome: Untriggered episodes lasting minutes to hours (Ménière's, vestibular migraine)
• Chronic Vestibular Syndrome: Persistent dizziness lasting weeks to months 2

2. Key Diagnostic Tests

• Dix-Hallpike test: Gold standard for diagnosing posterior canal BPPV 1
• Supine roll test: For lateral (horizontal) canal BPPV 1
• HINTS examination (Head-Impulse, Nystagmus, Test of Skew): More sensitive than early MRI for detecting stroke (100% vs 46%) 1
• Orthostatic vital sign measurement: Essential for identifying orthostatic intolerance 3

Treatment Approach

1. For BPPV (Most Common Cause)

• Canalith Repositioning Procedures (CRPs):
  • Epley maneuver for posterior canal BPPV
  • Barbecue roll or Gufoni maneuver for horizontal canal BPPV
  • Success rate of 80-90% with 1-2 treatments 1

2. Pharmacologic Management

• First-line medication: Meclizine 25-100 mg daily in divided doses for vertigo symptoms 4

  • Caution: May cause drowsiness; patients should avoid driving and alcohol 4

• For refractory symptoms:

  • Dopamine receptor antagonists: prochlorperazine (5-10 mg PO TID) or metoclopramide (5-10 mg PO QID)
  • Benzodiazepines: lorazepam (0.5-1 mg q4h PRN) for anxiety-related dizziness
  • Ondansetron for persistent nausea 1

3. Non-Pharmacologic Interventions

• Vestibular rehabilitation: Particularly beneficial for elderly patients and can decrease recurrence rates 1
• Regular physical activity: Cardio-exercise for at least 30 minutes twice weekly to improve balance 1

Management Algorithm Based on Etiology

For Peripheral Vertigo

1. BPPV:

   • Perform appropriate CRP based on canal involvement
   • Consider observation with follow-up as BPPV can resolve spontaneously 1

2. Vestibular Neuritis/Labyrinthitis:

   • Short course of steroids may be beneficial
   • Vestibular rehabilitation 1

For Central Vertigo

1. Stroke/TIA:

   • Urgent neuroimaging (MRI preferred over CT for posterior fossa lesions)
   • Neurology consultation 1

2. Vestibular Migraine:

   • Beta-blockers, anticonvulsants, or antidepressants for prophylaxis 1

For Orthostatic Dizziness

1. Orthostatic Hypotension:
   • Alpha agonists, mineralocorticoids
   • Lifestyle modifications (adequate hydration, gradual position changes) 1, 3

Common Pitfalls to Avoid

• Unnecessary imaging: CT or MRI is not needed to diagnose BPPV 1
• Overlooking medication side effects: Many medications can cause dizziness, especially in elderly patients 1
• Missing central causes: Failure to perform HINTS examination in acute vestibular syndrome can miss stroke 1
• Inadequate follow-up: Patients should be reassessed within 1 month to confirm symptom resolution 1

Patient Education

• Advise about increased fall risk, especially in elderly patients
• Teach recognition signs of recurrence, particularly with BPPV
• Instruct on home exercises for vestibular rehabilitation when appropriate 1

Remember that dizziness accounts for approximately 5% of primary care visits, with BPPV (22%) and stroke (20%) being the most common causes 5, 6. A systematic approach focusing on timing and triggers will lead to accurate diagnosis and effective management in most cases.