What is the best course of action for a 17-year-old experiencing nausea and dizziness?

Evaluation and Management of Nausea and Dizziness in a 17-Year-Old

For a 17-year-old presenting with nausea and dizziness, the priority is to rapidly distinguish benign peripheral vestibular conditions from life-threatening central causes using a timing-and-triggers approach, followed by targeted treatment based on the underlying etiology. 1, 2, 3

Initial Diagnostic Approach

Categorize by Timing and Triggers

The outdated approach of classifying dizziness by "type" (vertigo, presyncope, disequilibrium) should be abandoned in favor of categorizing patients into three groups based on timing and triggers 2, 3:

• Acute vestibular syndrome: Continuous dizziness lasting days, with nausea/vomiting, head motion intolerance, gait instability, and nystagmus 2, 3
• Spontaneous episodic vestibular syndrome: Recurrent episodes lasting minutes to hours without specific triggers 2, 3
• Triggered episodic vestibular syndrome: Brief episodes (seconds to minutes) provoked by specific head movements or position changes 2, 3

Critical Red Flags to Assess Immediately

• Focal neurological symptoms (weakness, numbness, speech changes, visual disturbances) suggest stroke or other central pathology 4
• Severe headache with sudden onset raises concern for intracranial hemorrhage or posterior circulation stroke 4
• Altered consciousness, confusion, or personality changes indicate serious central nervous system involvement 4
• Bradycardia or heart block with orbital trauma history may indicate oculocardiac reflex requiring urgent intervention 4
• Fever with neck stiffness suggests meningitis 4

Physical Examination Priorities

Essential Bedside Tests

• Orthostatic vital signs: Check for postural hypotension as a cause of dizziness 1
• Neurological examination: Assess for focal deficits, cranial nerve abnormalities, cerebellar signs 1, 5
• Assessment for nystagmus: Observe eye movements at rest and with gaze 1, 5
• Dix-Hallpike maneuver: Perform if symptoms are triggered by position changes to diagnose benign paroxysmal positional vertigo (BPPV) 1, 2, 3
• HINTS examination (head-impulse, nystagmus, test of skew): Use only in acute vestibular syndrome to differentiate peripheral from central causes 1, 2, 3

Heat-Related Illness Consideration

In adolescents with recent physical activity or heat exposure, consider heat exhaustion, which presents with nausea, dizziness, muscle cramps, headache, and heavy sweating 4:

• Immediate management: Move to cool environment, remove excess clothing, provide cool fluids with electrolytes and carbohydrates 4
• Escalation criteria: If central nervous system symptoms develop (confusion, seizures, syncope), suspect heat stroke and activate emergency services immediately 4

Treatment Based on Etiology

For Benign Paroxysmal Positional Vertigo (BPPV)

• Canalith repositioning procedures (Epley maneuver) are the most effective treatment 1
• Vestibular rehabilitation can be added for persistent symptoms 1

For Migraine-Associated Symptoms

In adolescents aged 12-17 years with migraine-related nausea and dizziness 4:

• First-line acute treatment: Ibuprofen at weight-appropriate dosing 4
• For nausea: Domperidone 10 mg can be used in adolescents 12-17 years 4
• Nasal triptans: Sumatriptan or zolmitriptan nasal spray are most effective for adolescents when NSAIDs fail 4
• Avoid bed rest alone unless attacks are very brief 4

For Non-Specific Nausea

First-line pharmacologic therapy 6:

• Metoclopramide: 10-20 mg orally three to four times daily, targeting both central and peripheral mechanisms 6
• Prochlorperazine: 5-10 mg four times daily or 10 mg every 6 hours as needed as an alternative 6

Second-line for refractory symptoms 6:

• Ondansetron: 4-8 mg twice or three times daily (5-HT3 antagonist) 6, 7
• Combination therapy: Metoclopramide plus ondansetron for persistent symptoms 6

Alternative agents 6:

• Meclizine: 12.5-25 mg three times daily for vestibular-related nausea 6
• Lorazepam: Effective for anxiety-related nausea 6

Critical Medication Warnings

• Metoclopramide: Risk of extrapyramidal side effects and tardive dyskinesia, particularly with prolonged use 6
• Ondansetron: Avoid in patients with congenital long QT syndrome; monitor ECG in those with electrolyte abnormalities, congestive heart failure, or bradyarrhythmias 7
• Serotonin syndrome risk: When combining 5-HT3 antagonists with SSRIs, SNRIs, or other serotonergic drugs, monitor for mental status changes, autonomic instability, neuromuscular symptoms 7

When to Escalate Care

Immediate emergency department referral is required for 4:

• Any focal neurological deficits
• Altered mental status or loss of consciousness
• Severe headache with sudden onset
• Signs of heat stroke (core temperature >40°C/104°F with CNS dysfunction)
• Suspected meningitis (fever, neck stiffness)
• Cardiovascular instability

Specialist referral indicated for 4, 1:

• Recurrent episodes despite appropriate acute treatment
• Diagnostic uncertainty after initial evaluation
• Need for vestibular rehabilitation
• Consideration of preventive migraine therapy

Common Pitfalls to Avoid

• Do not rely on symptom quality alone ("spinning" vs "lightheadedness") to guide diagnosis, as patient descriptions are often vague and inconsistent 2, 3
• Do not order routine imaging (CT/MRI) for typical BPPV or other clearly peripheral vestibular conditions 1
• Do not use pharmacologic vestibular suppressants long-term, as they impair central nervous system compensation 1
• Do not assume all dizziness with nausea is benign—always assess for central causes first 2, 3
• Do not delay cooling measures while waiting for temperature confirmation in suspected heat stroke 4