What is the appropriate management for dizziness in a 15-year-old female?

Management of Dizziness in a 15-Year-Old Female

Begin with a focused clinical assessment to categorize the dizziness pattern, as this determines both the diagnostic approach and treatment strategy, with the most critical initial step being to identify red flags requiring urgent neuroimaging versus benign peripheral causes that can be managed clinically.

Initial Clinical Assessment

The evaluation must immediately distinguish between four key presentations, as the diagnostic yield and management differ substantially 1:

• Brief episodic vertigo (seconds) triggered by head position changes suggests benign paroxysmal positional vertigo (BPPV) 1
• Spontaneous episodic vertigo (minutes to hours) with headache, photophobia, or phonophobia indicates vestibular migraine 1
• Acute persistent vertigo (days to weeks) suggests vestibular neuritis or central pathology 1
• Nonspecific lightheadedness may indicate presyncope, anxiety, or other systemic causes 2

Critical Red Flags Requiring Urgent Evaluation

Any of the following mandate immediate neurological examination and MRI brain imaging 1, 3:

• Focal neurological deficits (dysarthria, dysmetria, dysphagia, sensory/motor deficits) 3
• Inability to stand or walk independently 1
• New severe or massive headache preceding vertigo onset 3
• Sudden unilateral hearing loss 1
• Downbeating nystagmus or direction-changing nystagmus without head position change 1, 3
• Loss of consciousness 1
• Horner's syndrome 3

Important caveat: Posterior circulation stroke can present with no focal neurologic deficits on standard examination in 10% of cerebellar strokes, so maintain high suspicion in acute persistent vertigo 3.

Physical Examination Essentials

Mandatory Bedside Testing

• Dix-Hallpike maneuver: Perform immediately for any positionally-triggered symptoms to diagnose BPPV 1, 3
• Supine roll test: Evaluate for lateral canal BPPV if Dix-Hallpike is negative 3
• Neurologic examination: Specifically assess for focal deficits indicating central pathology 1
• Nystagmus assessment: Document characteristics, as downbeating or direction-changing nystagmus without position change indicates central pathology 1
• Gait and balance testing: Inability to stand/walk independently requires urgent evaluation 1

Imaging Decisions

Imaging is NOT necessary for 1:

• Brief episodic vertigo with typical BPPV features on Dix-Hallpike
• Spontaneous episodic vertigo consistent with vestibular migraine
• Acute persistent vertigo with normal neurologic exam and clear peripheral features

MRI brain without contrast is indicated for 1, 3:

• Any red flag symptoms listed above
• Failure of Dix-Hallpike maneuvers to reproduce or relieve symptoms 3
• Unilateral or pulsatile tinnitus 1
• Failure to respond to vestibular treatments 1
• Atypical presentation 1

Critical pitfall: CT head has poor sensitivity for posterior circulation pathology and should not substitute for MRI when stroke is suspected 1.

Treatment Based on Diagnosis

If BPPV Confirmed (Positive Dix-Hallpike)

• Perform Epley maneuver (canalith repositioning) immediately, as 91% of posterior canal BPPV resolves within 2 treatments 3, 2
• Success rates are 90-98% with proper technique 3
• If symptoms persist after 2-3 properly performed attempts, proceed to comprehensive vestibular function testing and neuroimaging 3
• Do not prescribe vestibular suppressants as primary treatment, as they do not address the underlying cause and may delay recovery 3

If Vestibular Migraine Suspected

Vestibular migraine is highly likely if the patient has 4, 1:

• ≥5 episodes of vestibular symptoms lasting 5 minutes to 72 hours
• Headache, photophobia, phonophobia during ≥50% of dizzy episodes
• Current or history of migraine
• Family history of migraine

First-line treatment approach 4:

1. Lifestyle modifications (initiate immediately):

   • Regular sleep schedule 4
   • Adequate hydration 4
   • Stress reduction techniques 4
   • Limiting salt/sodium, excessive caffeine, alcohol, and nicotine 4
   • Regular exercise 4

2. Preventive medications (if symptoms occur ≥2 days per month despite lifestyle modifications) 4:

   • Beta blockers (propranolol, metoprolol, atenolol, or bisoprolol) as first-line 4
   • Topiramate 50-100 mg daily (especially beneficial if obese) 4
   • Candesartan (angiotensin receptor blocker) 4

3. Acute attack management 4:

   • Triptans for concurrent headache 4
   • Short-term antiemetics (diphenhydramine, meclizine) 4

Treatment assessment: Evaluate efficacy after 2-3 months at therapeutic dose; consider pausing after 6-12 months of successful control 4.

Second-line options if first-line fails 4:

• Flunarizine 5-10 mg daily (avoid in depression) 4
• Amitriptyline 10-100 mg at night or nortriptyline (particularly useful with coexisting anxiety/depression) 4

Third-line for refractory cases 4:

• CGRP monoclonal antibodies (erenumab, fremanezumab, galcanezumab, eptinezumab) 4

If Vestibular Neuritis or Labyrinthitis

• Steroids for vestibular neuritis 2
• Vestibular rehabilitation exercises 5, 2
• Short-term vestibular suppressants only during acute phase 3

If Presyncope Pattern

• Orthostatic blood pressure testing 2
• Medication review, as many medications cause presyncope 2
• Treatment with alpha agonists, mineralocorticoids, or lifestyle changes if orthostatic hypotension confirmed 2

If Nonspecific Lightheadedness

• Consider psychiatric disorders (depression, anxiety, hyperventilation syndrome) 2
• Evaluate for systemic causes 2

Common Pitfalls to Avoid

• Do not assume BPPV when Dix-Hallpike is negative or unhelpful—this warrants further evaluation for alternative diagnoses 3
• Do not delay neurological evaluation when red flags are present, particularly severe headache preceding vertigo onset 3
• Do not prescribe long-term vestibular suppressants, as they are not recommended for chronic management and may delay recovery 4, 3
• Do not use opioids or barbiturates due to dependency risk, rebound symptoms, and questionable efficacy 4
• Do not abandon treatment prematurely, as efficacy takes weeks to months to establish 4
• Do not overlook multiple concurrent vestibular disorders, as 25-50% of patients with recurrent BPPV have associated vestibular pathology 3

Follow-Up Requirements

Reassess within 1 month to document resolution or persistence of symptoms 3. Earlier follow-up is warranted if 3:

• New neurological symptoms develop
• Symptoms worsen despite treatment
• Patient develops hearing loss, severe headache, or focal neurological deficits