What is the approach for evaluating and treating giddiness (dizziness)?

Evaluation and Treatment of Giddiness (Dizziness)

The most effective approach for evaluating and treating giddiness (dizziness) is to categorize the symptoms based on timing and triggers rather than subjective quality, followed by targeted examination and treatment specific to the identified cause. 1

Diagnostic Approach

Step 1: Categorize Dizziness Based on Timing and Triggers

• Episodic vertigo triggered by head motion suggests benign paroxysmal positional vertigo (BPPV) 1, 2
• Vertigo with unilateral hearing loss suggests Meniere disease 2
• Episodic vertigo without clear triggers may indicate vestibular neuritis 2
• Continuous dizziness with nausea, vomiting, and gait instability defines acute vestibular syndrome (AVS) 1

Step 2: Key Examination Components

• Dix-Hallpike maneuver: Essential for diagnosing posterior canal BPPV - observe for characteristic nystagmus 1
• Supine roll test: Perform if Dix-Hallpike is negative but BPPV is still suspected - evaluates for lateral canal BPPV 1
• HINTS examination: (Head-Impulse, Nystagmus, Test of Skew) - helps distinguish peripheral from central causes of vertigo 1, 2
• Orthostatic blood pressure measurement to evaluate for presyncope 2, 3
• Complete neurological examination to identify central nervous system disorders 1, 2

Step 3: Determine Peripheral vs. Central Etiology

• Peripheral causes (most common and generally benign):
  • BPPV, vestibular neuritis, Meniere disease, labyrinthitis 2, 3
• Central causes (require urgent evaluation):
  • Stroke, multiple sclerosis, tumors 1
• HINTS examination is more sensitive than early MRI (100% vs 46%) for detecting stroke in patients with AVS when performed by trained practitioners 1

Treatment Approach

For BPPV (Most Common Cause):

• Canalith Repositioning Procedure (CRP) such as the Epley maneuver is the first-line treatment 1, 2
• Success rates reach 90-98% when additional repositioning maneuvers are performed for persistent cases 1
• Vestibular rehabilitation exercises can be offered as initial treatment or adjunct therapy 1, 3

For Vestibular Neuritis:

• Vestibular suppressant medications for symptomatic relief 2, 3
• Vestibular rehabilitation exercises 2

For Meniere Disease:

• Salt restriction and diuretics 2, 3

For Medication-Related Dizziness:

• Meclizine (25-100 mg daily in divided doses) for vertigo associated with vestibular disorders 4
• Caution: May cause drowsiness; avoid in patients with history of asthma, glaucoma, or prostate enlargement due to anticholinergic effects 4
• Avoid routine use of vestibular suppressants like antihistamines or benzodiazepines 1

Important Considerations

When to Obtain Imaging

• Imaging is not recommended for typical BPPV with positive Dix-Hallpike test 1
• Consider MRI when:
  • Atypical nystagmus patterns are present 1
  • Neurological deficits accompany dizziness 1
  • HINTS examination suggests central etiology 1
  • Symptoms persist despite appropriate treatment 1

Follow-up and Patient Education

• Reassess patients within one month after initial treatment to confirm symptom resolution 1
• Educate patients about:
  • Increased fall risk associated with dizziness, especially in elderly patients 1
  • Potential for BPPV recurrence (5-13.5% at 6 months, 10-18% at 1 year, up to 36% long-term) 1
  • Need for prompt reevaluation if symptoms persist or recur 1

Treatment Failures

• Evaluate patients with persistent symptoms for:
  • Unresolved BPPV requiring additional repositioning maneuvers 1
  • Possible "canal conversion" (transformation from one type of BPPV to another) 1
  • Underlying peripheral vestibular or central nervous system disorders 1

Pitfalls to Avoid

• Relying solely on symptom quality descriptions rather than timing and triggers 1, 2
• Ordering unnecessary imaging for typical BPPV 1
• Missing central causes of vertigo that can mimic peripheral disorders 1
• Failing to recognize that approximately 20% of dizziness cases may not receive a definitive diagnosis 3
• Overlooking psychiatric disorders (anxiety, depression) as potential causes of vague lightheadedness 3