What is the management plan for a patient experiencing dizziness?

Management Plan for Dizziness

The management of dizziness should focus on identifying the underlying cause through timing and triggers rather than symptom quality, with specific treatments based on the diagnosis rather than routine use of vestibular suppressant medications.

Diagnostic Approach

Step 1: Categorize Dizziness Based on Timing and Triggers

• Episodic positional vertigo (seconds, triggered by position changes): Suggests BPPV
• Sudden severe vertigo (days duration): Consider vestibular neuritis or labyrinthitis
• Recurrent vertigo with hearing symptoms: Consider Ménière's disease
• Dizziness with standing: Evaluate for orthostatic hypotension
• Dizziness with neurological symptoms: Requires urgent evaluation for central causes

Step 2: Focused Physical Examination

1. Positional testing:

   • Dix-Hallpike maneuver for suspected BPPV
   • Observe for nystagmus (direction and duration)

2. Neurological assessment:

   • HINTS examination (Head-Impulse, Nystagmus, Test of Skew) for acute vestibular syndrome to differentiate peripheral from central causes 1
   • Full neurological examination for focal deficits

3. Cardiovascular assessment:

   • Orthostatic blood pressure measurement (drop of ≥20 mmHg systolic or ≥10 mmHg diastolic within 3 minutes of standing indicates orthostatic hypotension) 1

Step 3: Selective Diagnostic Testing

• Imaging is not routinely indicated for isolated vertigo without focal neurological deficits 1
• MRI brain (without contrast) is indicated for:
  • Acute vestibular syndrome with abnormal HINTS examination
  • Presence of neurological deficits
  • High vascular risk patients with acute vestibular syndrome 1

Treatment Plan by Diagnosis

1. Benign Paroxysmal Positional Vertigo (BPPV)

• First-line treatment: Canalith Repositioning Procedure (Epley maneuver) - 80% success rate 1
• Follow-up: Reassess within 1 month to confirm symptom resolution 2
• Avoid: Vestibular suppressant medications (antihistamines, benzodiazepines) 2

2. Vestibular Neuritis/Labyrinthitis

• Acute management: Early corticosteroid therapy 1
• Rehabilitation: Vestibular rehabilitation exercises to accelerate central compensation 1

3. Orthostatic Hypotension

• Management:
  • Medication adjustment (review and modify hypotensive medications)
  • Hydration
  • Compression stockings
  • Gradual position changes 1

4. Heart Failure with Dizziness and Low Blood Pressure

• For patients with heart failure experiencing dizziness with low blood pressure:
  • Asymptomatic/mild symptoms: Continue GDMT (guideline-directed medical therapy)
  • Initiate SGLT2i & MRA first as they don't lower BP significantly
  • Add low dose ARNI/ACEI or beta-blocker depending on clinical condition 2
  • Severe symptoms: Refer to heart failure specialist 2

Important Considerations

Medication Management

• Avoid routine use of vestibular suppressants such as antihistamines (meclizine) or benzodiazepines for BPPV 2
• Meclizine (25-100 mg daily in divided doses) may be used short-term for severe vertigo symptoms but not as definitive treatment 3
• Caution: Meclizine may cause drowsiness and has anticholinergic effects; use with care in patients with asthma, glaucoma, or prostate enlargement 3

Vestibular Rehabilitation

• Effective for persistent dizziness after BPPV resolution
• Can be self-administered or clinician-directed 1

Follow-up

• Reassess patients within 1 month after initial treatment to confirm symptom resolution 2
• If symptoms persist, consider referral to specialist (neurology, ENT)

Common Pitfalls to Avoid

1. Focusing on quality of dizziness rather than timing and triggers
2. Failing to perform the Dix-Hallpike maneuver in patients with positional vertigo
3. Routinely prescribing vestibular suppressants for BPPV
4. Missing central causes by not performing the HINTS examination
5. Ordering unnecessary imaging studies in patients with clear peripheral vertigo 1

Remember that approximately 20% of dizziness cases may not receive a definitive diagnosis, but symptomatic management and reassurance can still be effective in these cases.