What is the initial management for a patient experiencing dizziness?

Initial Management of Dizziness

The initial management of dizziness requires determining whether the patient has benign paroxysmal positional vertigo (BPPV) through the Dix-Hallpike maneuver, followed by immediate canalith repositioning procedures if positive, while avoiding routine imaging and vestibular suppressant medications. 1, 2

Immediate Diagnostic Steps

Perform the Dix-Hallpike Maneuver First

• Clinicians should diagnose posterior semicircular canal BPPV when vertigo associated with nystagmus (specifically torsional, upbeating) is provoked by the Dix-Hallpike maneuver. 1, 2
• This is a strong recommendation from the American Academy of Otolaryngology-Head and Neck Surgery and represents the single most important initial diagnostic step. 1

If Dix-Hallpike is Negative

• Perform the supine roll test to assess for lateral semicircular canal BPPV if the patient's history is compatible with BPPV but the Dix-Hallpike test is negative. 1, 2
• Differentiate BPPV from other causes including central disorders (stroke, migraine), other neurotologic conditions, and systemic conditions. 1, 2

Avoid Unnecessary Testing

• Do not order radiographic imaging or vestibular testing in patients who meet diagnostic criteria for BPPV unless additional neurological symptoms atypical for BPPV are present. 1, 2
• This reduces unnecessary costs and delays in treatment while avoiding false reassurance from normal imaging when BPPV is the actual diagnosis. 1

Immediate Treatment Algorithm

First-Line: Canalith Repositioning Procedures

• Treat patients with posterior canal BPPV immediately with the canalith repositioning maneuver (Epley maneuver). 1, 2
• For lateral canal BPPV, perform the roll maneuver (Lempert maneuver or barbecue roll). 2
• Cure rates reach 86-100% with up to 4 treatments for lateral canal BPPV. 1
• Post-procedural restrictions are not necessary after canalith repositioning. 2

Medication Management: Avoid Routine Use

• Do not routinely treat BPPV with vestibular suppressant medications such as antihistamines (meclizine) or benzodiazepines. 1
• These medications have no evidence for effectiveness as definitive treatment and carry significant risks including drowsiness, cognitive deficits, and increased fall risk—particularly dangerous in elderly patients. 1
• One controlled trial comparing diazepam, lorazepam, and placebo showed all groups had gradual symptom decline with no additional relief in the drug treatment arms. 1

Limited Exceptions for Medication Use

• Consider vestibular suppressants only for short-term management of severe autonomic symptoms (nausea, vomiting) in severely symptomatic patients who refuse therapy or as prophylaxis before canalith repositioning in patients with prior severe nausea. 1, 2
• Meclizine is FDA-approved for vertigo associated with vestibular system diseases but should be reserved for these limited indications. 3

Critical Safety Assessment

Assess Fall Risk Immediately

• Question patients about factors that modify management including impaired mobility or balance, CNS disorders, lack of home support, and increased risk for falling. 1, 2
• Elderly patients with BPPV have a 12-fold increased fall risk, and falls can cause fractures, brain injury, and unplanned hospital admissions. 2, 4
• Patients with central balance disorders have the highest fall rates (>50% recurrent fallers with odds ratio >10). 4
• Implement fall prevention strategies immediately, as patients with vestibular disorders have significantly higher fall risk. 2, 4

Screen for High-Risk Features

• Assess for comorbidities including migraine (present in 34% of BPPV patients vs 10% of controls), which may complicate management and increase treatment failures. 2
• Identify patients with prior head trauma or vestibular neuritis, as these have higher treatment failure rates due to widespread vestibular system dysfunction. 1
• Screen for physical limitations (cervical stenosis, severe rheumatoid arthritis, cervical radiculopathies, morbid obesity) that may require modified treatment approaches. 1

Follow-Up and Reassessment

Mandatory One-Month Reassessment

• Reassess patients within 1 month after initial treatment to confirm symptom resolution. 1, 2, 5
• For persistent symptoms, evaluate for unresolved BPPV, canal conversion (posterior to lateral or vice versa occurring in up to 6% of cases), involvement of multiple canals, or underlying peripheral vestibular or CNS disorders. 1

Treatment Failures Require Investigation

• CNS disorders masquerading as BPPV are found in 3% of treatment failures. 1
• Consider vestibular rehabilitation as adjunctive therapy for patients with residual generalized dizziness or postural control abnormalities even after successful canalith repositioning. 1, 2, 5

Patient Education Requirements

Mandatory Counseling Points

• Educate patients regarding the impact of BPPV on their safety, the potential for disease recurrence, and the importance of follow-up. 1, 2
• Discuss that balance will be "off" and precautions against falls are necessary until BPPV is successfully treated. 1
• Explain that BPPV can recur and there is no proven prevention method, but it can be treated with high success rates. 1, 2
• Provide written instructions for home exercise programs if vestibular rehabilitation is prescribed. 2

Common Pitfalls to Avoid

• Do not assume initial treatment failure means the diagnosis is wrong—it may indicate canal conversion, multiple canal involvement, or incorrect initial canal identification. 1
• Do not prescribe long-term vestibular suppressants, as they delay natural balance recovery and impede vestibular compensation. 5
• Do not dismiss persistent symptoms as psychological—coexisting vestibular dysfunction from Menière's disease, migraine, or prior vestibular neuritis can prolong symptoms and increase recurrence risk. 1