What is the approach to diagnosing and managing vertigo (dizziness)?

From the Guidelines

The approach to vertigo should begin with distinguishing between peripheral and central causes through careful history and examination, and for peripheral vertigo, such as Benign Paroxysmal Positional Vertigo (BPPV), treatment includes repositioning maneuvers like the Epley maneuver, as recommended by the American Academy of Otolaryngology-Head and Neck Surgery Foundation 1.

Key Considerations

• The diagnosis of BPPV should be made based on clinical history and physical examination, including the Dix-Hallpike maneuver and supine roll test, as these are crucial for identifying the condition and guiding treatment 1.
• Repositioning procedures, such as the canalith repositioning procedure, should be used as initial therapy for patients with posterior canal BPPV, given their high success rates and the recommendation by the American Academy of Otolaryngology-Head and Neck Surgery Foundation 1.
• Clinicians should not recommend postprocedural postural restrictions after canalith repositioning procedure for posterior canal BPPV, as this is not supported by evidence and may unnecessarily restrict patient activity 1.
• Vestibular rehabilitation, either self-administered or with a clinician, may be offered in the treatment of BPPV to promote long-term recovery and reduce the risk of falls 1.
• Medical therapy with vestibular suppressant medications such as antihistamines and/or benzodiazepines should not be routinely used for BPPV, as they can delay central compensation and are not recommended by current guidelines 1.

Management Strategies

• For patients with BPPV, education regarding the impact of the condition on their safety, the potential for disease recurrence, and the importance of follow-up is crucial for managing the condition effectively and preventing complications 1.
• Clinicians should reassess patients within 1 month after an initial period of observation or treatment to document resolution or persistence of symptoms, and evaluate patients with persistent symptoms for unresolved BPPV and/or underlying peripheral vestibular or central nervous system disorders 1.
• The role of patient preferences in making decisions about BPPV management should be considered, with clinicians providing clear and comprehensible information on the benefits and risks of different treatments to facilitate patient understanding and shared decision making 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).

The approach to vertigo involves the use of meclizine hydrochloride tablets for the treatment of vertigo associated with diseases affecting the vestibular system in adults.

• The recommended dosage is 25 mg to 100 mg daily, in divided doses 2.
• Key considerations include potential drowsiness and anticholinergic action, which may impact patients with certain medical conditions, such as asthma, glaucoma, or enlargement of the prostate gland.
• Patients should be cautioned about CNS depression when meclizine is coadministered with other CNS depressants, including alcohol 2.

From the Research

Approach to Vertigo

The approach to vertigo involves identifying the underlying cause and guiding management decisions based on whether the vertigo is peripheral or central in origin 3.

• Common Causes of Vertigo: The most common causes of vertigo include benign paroxysmal positional vertigo (BPPV), acute vestibular neuronitis or labyrinthitis, Ménière's disease, migraine, and anxiety disorders 3.
• Diagnostic Testing: Most patients with vertigo do not require extensive diagnostic testing and can be treated in the primary care setting 3.
• Treatment Options: Treatment options for vertigo include:
  • Benign paroxysmal positional vertigo: canalith repositioning procedure, such as the Epley maneuver 3, 4, 5
  • Acute vestibular neuronitis or labyrinthitis: initial stabilizing measures and a vestibular suppressant medication, followed by vestibular rehabilitation exercises 3, 6, 7
  • Ménière's disease: low-salt diet and diuretics 3
  • Vertiginous migraine headaches: dietary changes, a tricyclic antidepressant, and a beta blocker or calcium channel blocker 3
  • Vertigo associated with anxiety: selective serotonin reuptake inhibitor 3

Management of BPPV

The most efficient management of BPPV is to perform a bedside test (Dix-Hallpike test) and then to treat the patients with a bedside positional (the Epley) maneuver 4.

• Benefits of the Epley Maneuver: The Epley maneuver has been shown to be more effective than vestibular rehabilitation at 1-week follow-up in terms of patient-reported symptom relief and conversion of the Dix-Hallpike maneuver from positive to negative 5.
• Vestibular Rehabilitation: Vestibular rehabilitation therapy (VRT) is an exercise-based treatment program designed to promote vestibular adaptation and substitution, and is indicated for any stable but poorly compensated vestibular lesion 6, 7.

Vestibular Rehabilitation

Vestibular rehabilitation therapy (VRT) facilitates vestibular recovery mechanisms, including vestibular adaptation, substitution by the other eye-movement systems, substitution by vision, somatosensory cues, other postural strategies, and habituation 7.

• Key Exercises for VRT: The key exercises for VRT include head-eye movements with various body postures and activities, and maintaining balance with a reduced support base with various orientations of the head and trunk, while performing various upper-extremity tasks 7.