What are the initial steps to manage dizziness in an adolescent?

Initial Management of Dizziness in a 15-Year-Old Adolescent

Focus on timing and triggers of the dizziness rather than the adolescent's subjective description, as this approach is more diagnostically valuable and will guide your entire evaluation. 1

Step 1: Classify the Dizziness Pattern

Determine which of four vestibular syndromes applies 2, 1:

• Triggered episodic (seconds to <1 minute): Provoked by specific head/body position changes → suggests BPPV 1
• Spontaneous episodic (minutes to hours): No specific trigger → consider vestibular migraine or Ménière's disease 2
• Acute vestibular syndrome (days to weeks): Continuous symptoms → consider vestibular neuritis or central causes 2
• Chronic vestibular syndrome (weeks to months): Persistent symptoms → consider medication effects, anxiety, or post-traumatic vertigo 1

Step 2: Focused History - Key Details to Elicit

Duration and frequency: Exact timing of each episode (seconds vs minutes vs hours) 1

Specific triggers: 2, 1

• Head position changes (BPPV)
• Pressure changes from coughing/straining (superior canal dehiscence)
• No trigger (vestibular migraine, Ménière's)

Associated symptoms: 2, 1

• Hearing loss, tinnitus, or aural fullness (Ménière's disease)
• Headache, photophobia, phonophobia (vestibular migraine)
• Recent viral illness (vestibular neuritis)

Medication review: Antihypertensives, sedatives, anticonvulsants can cause chronic dizziness 1

Trauma history: Recent head injury or concussion 1

Step 3: Physical Examination - Specific Maneuvers

Perform the Dix-Hallpike maneuver for suspected BPPV (most common in adolescents with triggered episodic symptoms) 1, 3:

• Positive test shows: 5-20 second latency, torsional upbeating nystagmus toward affected ear, symptoms resolve within 60 seconds 1, 4

Supine roll test for lateral canal BPPV (10-15% of cases) 4

Neurologic examination: 2, 1

• Check for focal deficits, ataxia, inability to stand/walk
• Assess for abnormal nystagmus patterns (downbeating, direction-changing without position change)

Orthostatic vital signs: Rule out postural hypotension 5, 6

Step 4: Immediate Treatment Based on Findings

If BPPV is Confirmed (Positive Dix-Hallpike):

Perform the Epley maneuver immediately - this is first-line treatment with 70-80% resolution after single treatment, 90-98% after repeat maneuvers 3, 4

Do NOT prescribe vestibular suppressant medications (meclizine, antihistamines, benzodiazepines) as primary treatment - they are ineffective for BPPV and have no role except for severe nausea during the maneuver itself 2, 3, 4

No imaging or vestibular testing needed for typical BPPV with positive Dix-Hallpike and normal neurologic exam 1

If Red Flags Are Present - Urgent Evaluation Required:

Obtain MRI brain without contrast immediately for any of these findings 2, 1, 3:

• Focal neurological deficits
• Sudden hearing loss
• Inability to stand or walk independently
• Downbeating nystagmus or other central nystagmus patterns
• New severe headache accompanying dizziness
• Failure to respond to appropriate repositioning maneuvers

Critical pitfall: 75-80% of patients with posterior circulation stroke have NO focal neurologic deficits, so a normal neurologic exam does not exclude stroke 1

Step 5: Follow-Up and Patient Education

Reassess within 1 month to confirm symptom resolution 2, 3

Counsel the adolescent and family about: 2, 3

• BPPV recurrence risk (10-18% at 1 year, up to 36% long-term)
• Increased fall risk during symptomatic periods
• Return promptly if symptoms recur for repeat repositioning
• No activity restrictions after successful treatment 4

Common Pitfalls to Avoid

Do not rely on CT imaging - it has <1% diagnostic yield for isolated dizziness and misses most posterior circulation infarcts 1

Do not order comprehensive vestibular testing for straightforward BPPV - it delays treatment unnecessarily 1

Do not assume "lightheadedness" vs "spinning" descriptions are diagnostically useful - timing and triggers are far more reliable 2, 1

Do not prescribe meclizine or other vestibular suppressants as primary treatment for BPPV - success rate is only 30.8% vs 78.6-93.3% for repositioning maneuvers 3