What is the best course of action for a patient experiencing severe dizziness?

Management of Severe Dizziness

For a patient with severe dizziness, immediately determine the timing pattern (acute persistent vs. brief episodic vs. spontaneous episodic) and perform targeted physical examination including the Dix-Hallpike maneuver for brief episodes or HINTS examination for acute persistent symptoms, rather than initiating medications, as vestibular suppressants are not recommended for routine treatment and can cause significant harm including falls and delayed recovery. 1, 2

Initial Diagnostic Approach

Classify by Timing Pattern

The most critical first step is categorizing dizziness by duration and triggers, not by the patient's subjective description of "spinning" versus "lightheadedness" 2, 3:

• Brief episodic vertigo: Seconds to <1 minute, triggered by head position changes—suggests BPPV (most common, 42% of vertigo cases) 2, 3
• Acute persistent vertigo: Days to weeks of constant symptoms—suggests vestibular neuritis or stroke 2
• Spontaneous episodic vertigo: Minutes to hours without positional triggers—suggests vestibular migraine or Ménière's disease 3

Identify Red Flags Requiring Urgent Evaluation

Critical warning signs that mandate immediate imaging and neurologic consultation 2, 4:

• Focal neurological deficits (dysarthria, dysmetria, sensory/motor deficits) 3, 4
• Sudden hearing loss 2
• New severe headache 2
• Inability to stand or walk 2
• Downbeating nystagmus or other central nystagmus patterns 2, 3
• Failure to respond to appropriate vestibular treatments 2

Important caveat: 75-80% of patients with posterior circulation stroke presenting with acute vestibular syndrome have NO focal neurologic deficits, so absence of these findings does not exclude stroke in high-risk patients 2, 3, 4

Physical Examination Protocol

For Brief Episodic Symptoms (Suspected BPPV)

Perform the Dix-Hallpike maneuver as the gold standard diagnostic test 2, 3:

• Positive findings: 5-20 second latency, torsional upbeating nystagmus toward affected ear, symptoms that increase then resolve within 60 seconds 2, 3
• If positive with typical features and no red flags: No imaging or vestibular testing is indicated 1, 2

For Acute Persistent Symptoms

Perform HINTS examination (Head Impulse, Nystagmus, Test of Skew) if trained in the technique 2, 3:

• When performed by trained practitioners, HINTS has 100% sensitivity for detecting stroke (superior to early MRI at 46% sensitivity) 2, 3
• Critical limitation: Results are unreliable when performed by non-experts 2
• If HINTS suggests central cause OR examiner not trained: obtain MRI brain without contrast urgently 2

Management Based on Diagnosis

For Confirmed BPPV (Most Common Cause)

Perform canalith repositioning procedure (Epley maneuver) as first-line treatment 1, 2, 3:

• Success rates: 90-98% when additional maneuvers performed for persistent cases 2
• Do NOT prescribe vestibular suppressant medications routinely 1
• No post-procedural postural restrictions needed 1

Medication Use: Highly Restricted Indications Only

Vestibular suppressants are NOT recommended for routine treatment and should be reserved only for 1:

• Short-term management of severe nausea/vomiting in severely symptomatic patients 1, 4
• Prophylaxis before canalith repositioning in patients who previously experienced severe nausea with Dix-Hallpike maneuvers 1, 4
• Patients who become severely symptomatic immediately after repositioning procedure 1

If antiemetic needed: Prochlorperazine 5-10 mg orally or IV, maximum three doses per 24 hours 4

Meclizine (25-100 mg daily in divided doses) is FDA-approved for vertigo associated with vestibular system diseases 5, but guideline evidence shows it provides no benefit over placebo for BPPV and can cause significant harm 1

Critical Harms of Vestibular Suppressants

Avoid prolonged use due to 1, 3:

• Significant fall risk, especially in elderly (benzodiazepines are independent risk factor) 1
• Drowsiness and cognitive deficits 1, 5
• Interference with central vestibular compensation and delayed recovery 3, 4
• Polypharmacy risks in elderly patients 1

Imaging Decisions

When NOT to Image

No imaging indicated for 1, 2:

• Brief episodic vertigo with typical BPPV features and positive Dix-Hallpike 1, 2
• Acute persistent vertigo with normal neurologic exam AND HINTS consistent with peripheral vertigo by trained examiner 2

When to Obtain MRI Brain Without Contrast

MRI (not CT) is indicated for 2:

• Acute persistent vertigo with abnormal neurologic examination 2
• HINTS examination suggesting central cause 2
• High vascular risk patients with acute vestibular syndrome 2
• Unilateral or pulsatile tinnitus 2
• Asymmetric hearing loss 2

CT head has very low yield (<1%) for isolated dizziness and misses most posterior circulation infarcts 2

Special Considerations for Heart Failure Patients

If patient has heart failure with reduced ejection fraction on guideline-directed medical therapy 1:

• Mild dizziness upon standing is common and typically does NOT require medication reduction 1
• Patient education and counseling often sufficient—reassure that transient dizziness is side effect of life-prolonging medications 1
• If stable on optimal therapy with low blood pressure: look for OTHER causes (valvular disease, ischemia, alpha-blockers for BPH) before adjusting HF medications 1
• Consider diuretic reduction only if no signs of congestion present 1

Follow-Up Protocol

Reassess within 1 month after initial treatment to document 2, 4:

• Resolution or persistence of symptoms 2, 4
• Quality of life changes 4
• Need for alternative diagnosis consideration if symptoms persist 4

Counsel patients about 2:

• Recurrence risk of BPPV 2
• Fall risk, especially in elderly 2
• Importance of returning promptly if symptoms recur for repeat repositioning 2