What is the approach to patients with vertigo (dizziness)?

From the Guidelines

The approach to patients with vertigo should begin with a thorough history and physical examination to distinguish between peripheral and central causes, with a focus on identifying red flags such as neurological symptoms, and then proceed with targeted diagnostic testing and treatment based on the likely cause, as outlined in the most recent guidelines 1.

Key Considerations

• A thorough history is essential, focusing on onset, duration, triggers, and associated symptoms, to differentiate between vertigo, presyncope, disequilibrium, and non-specific dizziness.
• Physical examination should include vital signs, orthostatic measurements, neurological assessment, and specialized tests like the Dix-Hallpike maneuver for benign paroxysmal positional vertigo (BPPV) 1.
• For BPPV, the Epley maneuver can be performed immediately for treatment, while vestibular neuritis may require symptomatic treatment with antihistamines or antiemetics.
• Ménière's disease often responds to low-salt diet and diuretics, and central causes require neuroimaging, as recommended in the latest clinical practice guidelines 1.

Diagnostic Approach

• The diagnosis of posterior semicircular canal BPPV should be made when vertigo associated with torsional, upbeating nystagmus is provoked by the Dix-Hallpike maneuver 1.
• The supine roll test should be performed to assess for lateral semicircular canal BPPV if the Dix-Hallpike test is negative 1.
• Radiographic imaging should not be obtained in patients who meet diagnostic criteria for BPPV in the absence of additional signs and/or symptoms inconsistent with BPPV that warrant imaging 1.

Treatment Options

• The Epley maneuver is recommended as initial therapy for patients with posterior canal BPPV 1.
• Vestibular rehabilitation may be offered as an additional treatment option for patients with BPPV 1.
• Medical therapy with vestibular suppressant medications should not be routinely used to treat BPPV 1.

Recent Guidelines

• The 2020 clinical practice guideline for Ménière's disease emphasizes the importance of a thorough history and physical examination in diagnosing and managing the condition 1.
• The 2024 ACR Appropriateness Criteria for dizziness and ataxia provide guidance on the use of imaging tests, including CT and MRI, in the evaluation of patients with vertigo and ataxia 1.

From the FDA Drug Label

MECLIZINE HYDROCHLORIDE tablets, for oral use Initial U. S. Approval: 1957 INDICATIONS AND USAGE Meclizine hydrochloride tablets are indicated for the treatment of vertigo associated with diseases affecting the vestibular system in adults (1). DOSAGE AND ADMINISTRATION Recommended dosage: 25 mg to 100 mg daily, in divided doses (2.1).

The approach to patients with vertigo (dizziness) is to treat them with meclizine hydrochloride tablets at a recommended dosage of 25 mg to 100 mg daily, in divided doses.

• The treatment is specifically indicated for vertigo associated with diseases affecting the vestibular system in adults.
• Patients should be advised to swallow the tablets whole 2.

From the Research

Approach to Patients with Vertigo (Dizziness)

The approach to patients with vertigo or dizziness involves several key steps, including:

• A thorough history and physical examination to identify the underlying cause of dizziness 3, 4, 5, 6, 7
• Distinguishing between serious and benign causes of dizziness, such as central nervous system lesions, brainstem ischemia, cardiac arrhythmia, and endocrine abnormalities 3, 4
• Recognizing diseases that can be specifically treated, such as Meniere's disease, middle ear infections, and drug reactions 3
• Considering the duration and characteristics of the dizziness, including whether it is acute or chronic, episodic or continuous, and whether it is evoked by or brought on by an event or circumstance 6

Diagnostic Categories

Dizziness can be categorized into several main types, including:

• Vertigo: a sensation of spinning or rotation 7
• Presyncope/syncope: a feeling of lizziness or fainting 7
• Disequilibrium: a sense of imbalance or unsteadiness 7
• Nonspecific symptoms: a general feeling of dizziness or lizziness without a specific cause 7

Diagnostic Tests

Diagnostic tests should be ordered for patients who have abnormal findings on physical examination that may indicate a more serious cause of dizziness 7. However, additional tests are rarely necessary, and a thorough history and physical examination are often sufficient to diagnose and treat the underlying cause of dizziness 3, 5.