What are the initial steps to manage dizziness?

Initial Management of Dizziness

Begin by classifying dizziness based on timing and triggers rather than patient descriptions, then perform the Dix-Hallpike maneuver immediately if episodic positional symptoms are present, as BPPV accounts for 42% of vertigo cases and is definitively treatable at the bedside. 1

Step 1: Classification by Timing Pattern (Not Quality)

Patient descriptions of dizziness quality are unreliable and inconsistent. 2, 3 Instead, focus on:

• Triggered episodic dizziness (seconds to minutes, provoked by head position changes): Most likely BPPV 1, 4
• Spontaneous episodic dizziness (minutes to hours, unprovoked): Consider vestibular migraine, Ménière's disease, or vestibular neuritis 1, 2
• Chronic persistent dizziness (constant, daily): Consider medication effects, orthostatic hypotension, or central pathology 1, 3

Step 2: Immediate Bedside Testing

For Triggered Episodic Dizziness:

• Perform the Dix-Hallpike maneuver for posterior canal BPPV (most common): Bring patient from upright to supine with head turned 45° to one side and neck extended 20°, looking for torsional upbeating nystagmus 5, 4
• If Dix-Hallpike shows horizontal or no nystagmus, perform the supine roll test for lateral canal BPPV 5, 1
• If positive, perform the Epley maneuver immediately at the same visit—success rates are 90-98% 1, 4

For All Patients:

• Orthostatic vital signs: Measure blood pressure supine and after 3 minutes standing to identify orthostatic hypotension (drop ≥20 mmHg systolic or ≥10 mmHg diastolic) 5, 1
• Assess for central nystagmus patterns: Direction-changing nystagmus without head position changes, downward nystagmus, or spontaneous nystagmus without provocation all indicate CNS pathology requiring urgent evaluation 1, 6

Step 3: Medication Review

If blood pressure is stable and patient is on cardiovascular medications, do NOT assume medications are the cause—actively search for other etiologies first. 1 This is a critical pitfall that leads to inappropriate discontinuation of life-saving therapy. 1

• Identify all potentially causative medications: antihypertensives, diuretics, anticonvulsants, benzodiazepines 1, 3
• In heart failure patients stable on guideline-directed therapy, transient mild dizziness upon standing is expected and does NOT require dose reduction 1
• If congestion is absent, cautiously reduce diuretics before touching other cardiovascular medications 1

Step 4: Treatment Based on Diagnosis

BPPV (Most Common):

• Canalith repositioning procedure (Epley maneuver) is first-line treatment 5, 4
• Do NOT prescribe vestibular suppressants (meclizine, antihistamines, benzodiazepines)—they do not address the underlying cause and impede vestibular compensation 5, 4
• Do NOT recommend post-procedural positioning restrictions—they provide no benefit 5
• If symptoms persist after 2-3 repositioning attempts, consider MRI brain to exclude central pathology 1, 6

Orthostatic Hypotension:

• Address volume depletion, review medications, consider alpha agonists or mineralocorticoids if lifestyle modifications fail 7, 2

Vestibular Neuritis/Labyrinthitis:

• Short-term vestibular suppressants (3-5 days maximum) for severe acute symptoms only 4, 2
• Vestibular rehabilitation therapy as primary treatment 4, 2

Step 5: When to Image

Avoid CT head for isolated dizziness—diagnostic yield is less than 1% and sensitivity is only 20-40% for causative pathology. 1

Order MRI brain (not CT) only for: 1, 6

• Atypical or refractory symptoms after 2-3 repositioning attempts
• Central nystagmus patterns (direction-changing, downward, spontaneous)
• Associated neurological symptoms (diplopia, dysarthria, ataxia, focal weakness)
• Persistent isolated dizziness with high vascular risk factors

Critical Red Flags Requiring Urgent Evaluation

• New severe headache with dizziness (consider posterior circulation stroke) 6, 3
• Focal neurological deficits 6, 3
• Central nystagmus patterns 1, 6
• Inability to stand or walk (consider cerebellar stroke—10% initially mimic peripheral vestibular processes) 6
• Acute hearing loss with vertigo (consider labyrinthitis or stroke) 2, 3

Common Pitfalls to Avoid

• Do not assume cardiovascular medications cause dizziness in stable patients—this leads to inappropriate discontinuation of life-saving therapy 1
• Do not order imaging for typical BPPV—the Dix-Hallpike maneuver is diagnostic and imaging is unnecessary 5, 1
• Do not prescribe meclizine for BPPV—it does not treat the underlying cause and may worsen outcomes 5, 4
• Do not rely on patient descriptions of dizziness quality—focus on timing and triggers instead 2, 3

Follow-Up

Reassess within 1 month to document resolution or persistence of symptoms. 4 For persistent symptoms, evaluate for unresolved BPPV, canal conversion, or underlying peripheral vestibular or CNS disorders. 5, 4