What is the appropriate evaluation and management for a truck driver experiencing dizziness?

Evaluation and Management of Dizziness in a Truck Driver

A comprehensive evaluation of dizziness in a truck driver requires special attention to occupational safety concerns, with mandatory referral to a board-certified sleep medicine specialist if specific risk factors are present, and careful assessment for vestibular, cardiovascular, and neurological causes. 1, 2

Initial Assessment Framework

Characterize the Type of Dizziness

• Vertigo: Sensation of spinning or rotation
  • Assess for nystagmus and perform Dix-Hallpike maneuver
  • Consider BPPV, vestibular neuritis, Menière's disease, or stroke
• Presyncope: Near-fainting sensation
  • Check orthostatic vital signs (drop of ≥20 mmHg systolic or ≥10 mmHg diastolic within 3 minutes of standing)
  • Evaluate for cardiac causes (arrhythmias, structural heart disease)
• Disequilibrium: Unsteadiness when walking
  • Assess gait, balance, and proprioception
  • Consider peripheral neuropathy, cerebellar disorders
• Lightheadedness: Vague sensation of disconnection
  • Consider anxiety, hyperventilation, medication side effects

Critical Occupational Considerations

• Commercial drivers with dizziness require more stringent evaluation due to public safety concerns 2
• Assess for sleep disorders, particularly obstructive sleep apnea (OSA) 2
• Mandatory referral to sleep medicine specialist if:
  1. BMI ≥ 40 kg/m²
  2. BMI ≥ 33 kg/m² with hypertension requiring ≥2 medications or type 2 diabetes
  3. History of sleepiness-related crashes or accidents 2

Diagnostic Approach

Key Physical Examination Elements

• HINTS examination (Head-Impulse, Nystagmus, Test of Skew) - more sensitive than early MRI for stroke detection 1
• Dix-Hallpike maneuver for suspected BPPV
• Orthostatic vital signs to assess for orthostatic hypotension
• Complete neurological examination including cranial nerves, coordination, and gait
• Cardiovascular assessment including heart rate and rhythm

Targeted Testing Based on Clinical Suspicion

• Audiogram: For suspected Menière's disease with hearing loss
• ECG/Holter monitoring: For suspected arrhythmias
• MRI brain: For acute vestibular syndrome with abnormal HINTS exam or neurological deficits
• Blood tests: Consider CBC, electrolytes, glucose, thyroid function, and HbA1c

Management Approach

Condition-Specific Treatment

1. BPPV: Canalith Repositioning Procedure (Epley maneuver) - 80% success rate 1
2. Vestibular neuritis: Early corticosteroid therapy 1
3. Orthostatic hypotension: Medication adjustment, hydration, compression stockings 1
4. Medication-induced dizziness: Review and adjust medications, particularly:
   • Antihypertensives (diuretics, β-blockers, ACE inhibitors)
   • Psychotropics (antidepressants, antipsychotics)
   • Antihistamines 1
5. Vertigo: Meclizine for symptomatic relief of vertigo associated with vestibular disorders 3

Vestibular Rehabilitation

• Effective for persistent dizziness after BPPV resolution
• Can be self-administered or clinician-directed
• Accelerates central compensation for vestibular imbalance 1

Driving Fitness Assessment

Risk Evaluation

• The risk of causing harm while driving must be carefully assessed 2
• Commercial drivers are held to stricter standards than private drivers due to:
  • Greater time spent driving
  • Heavier vehicles
  • Potential for greater harm in accidents 2

Return-to-Work Considerations

• Temporary driving restriction may be necessary until symptoms resolve
• Regulatory agencies are more likely to disqualify commercial drivers than private drivers 2
• Documentation of treatment effectiveness and symptom resolution is essential before return to driving

Common Pitfalls to Avoid

• Focusing on quality of dizziness rather than timing and triggers
• Failing to perform the Dix-Hallpike maneuver in patients with positional vertigo
• Routinely prescribing vestibular suppressants for BPPV
• Missing central causes of vertigo by not performing the HINTS examination
• Ordering unnecessary imaging studies in patients with clear peripheral vertigo 1
• Neglecting to screen for OSA in commercial drivers with risk factors 2

Special Consideration: Motorist's Vestibular Disorientation Syndrome

• Consider in professional drivers experiencing disorientation specifically while driving
• Common triggers: higher speeds (>80 km/h), multi-lane roads, bends and turns
• Often associated with history of migraines (62.5%) and motion sickness (50%)
• May respond to migraine prophylactic treatments 4