What are the appropriate evaluation and treatment steps for a patient experiencing dizziness, possibly due to conditions like benign paroxysmal positional vertigo (BPPV) or orthostatic hypotension, and who may be taking medications such as antihypertensive medications?

Evaluation and Management of Dizziness

Initial Diagnostic Approach

Focus your history on timing and triggers of dizziness rather than the patient's descriptive terms, as this approach is more clinically useful and reliable for diagnosis. 1

Classify by Timing and Triggers

The most effective diagnostic framework categorizes dizziness into four distinct vestibular syndromes based on temporal patterns 1:

• Triggered Episodic Vestibular Syndrome: Episodes lasting <1 minute triggered by specific head or body position changes (e.g., rolling over in bed, looking up) strongly suggest BPPV 1

• Spontaneous Episodic Vestibular Syndrome: Episodes lasting minutes to hours without specific triggers suggest vestibular migraine, Ménière's disease, or posterior circulation TIA 1

• Acute Vestibular Syndrome: Continuous dizziness lasting days to weeks with nausea, vomiting, and intolerance to head motion suggests vestibular neuritis, labyrinthitis, or posterior circulation stroke 1

• Chronic Vestibular Syndrome: Dizziness lasting weeks to months suggests anxiety/panic disorder, medication side effects, posttraumatic vertigo, or posterior fossa mass lesions 1

Critical Differential Diagnosis Considerations

Postural hypotension must be distinguished from BPPV by the specific trigger: dizziness provoked by moving from supine to upright position (not by head position changes relative to gravity). 1

Other key differentials include 1:

• Medication side effects: Antihypertensive medications, cardiovascular medications, carbamazepine, phenytoin, and Mysoline commonly cause dizziness 1
• Cervicogenic vertigo: Triggered by head rotation relative to the body while upright (not by head position changes relative to gravity) 1
• Vestibular migraine: Spontaneous episodic pattern without positional triggers 1

Physical Examination

Essential Maneuvers

Perform the Dix-Hallpike maneuver for any patient with triggered episodic dizziness to diagnose or exclude BPPV. 1

The examination should include 2, 3:

• Orthostatic vital signs: Measure blood pressure and heart rate supine, then after 1 and 3 minutes of standing to identify orthostatic hypotension 2, 3

• Dix-Hallpike maneuver: Positive test shows rotatory nystagmus with latency of a few seconds, fatigues with repeated testing, and reproduces the patient's vertigo symptoms 1

• HINTS examination (Head-Impulse, Nystagmus, Test of Skew): Use this only for patients with acute vestibular syndrome to distinguish dangerous central causes from benign peripheral causes 2, 3

Common Pitfall to Avoid

Do not rely on imaging or laboratory testing for routine dizziness evaluation—the diagnosis is clinical, based on history and physical examination. 4, 2, 3

Treatment Based on Etiology

BPPV (Most Common Cause)

Treat BPPV with canalith repositioning procedures (Epley maneuver), which directly address the underlying pathophysiology and are highly effective. 2, 3

• The Epley maneuver should be performed in the office for immediate symptom relief 2, 3
• Do NOT use vestibular suppressant medications (antihistamines, benzodiazepines, or meclizine) for BPPV treatment, as they are ineffective and interfere with central compensation 5
• Vestibular rehabilitation can be added if symptoms persist after repositioning maneuvers 2, 3

Counsel patients that BPPV has a 10-18% recurrence rate at 1 year and up to 36% long-term, so they should return promptly if symptoms recur. 1

Orthostatic Hypotension

For medication-induced orthostatic hypotension, review and adjust the patient's antihypertensive regimen as the primary intervention. 1, 6

Management strategies include 6:

• Ensure adequate hydration 6
• Instruct patients to rise slowly from sitting or lying positions 6
• Consider switching alpha-blockers: tamsulosin has lower orthostatic hypotension risk than alfuzosin 6
• Warn patients about dizziness risk when driving or operating machinery, especially elderly patients 6

Medication Review

Systematically review all medications in patients with dizziness, as polypharmacy and multiple hypotensive agents significantly increase risk. 1, 6

High-risk medications include 1, 6:

• Antihypertensive medications (especially alpha-blockers like alfuzosin) 1, 6
• Cardiovascular medications 1
• Anticonvulsants (carbamazepine, phenytoin, Mysoline) 1
• Anticholinergic medications (independent fall risk factor in elderly) 7

Special Populations and Modifying Factors

Elderly and Fall Risk

Counsel all patients with BPPV about increased fall risk, particularly elderly and frail patients who require home safety assessment and possible supervision until symptoms resolve. 1

Key counseling points 1:

• 53% of elderly patients with vestibular disorders fall at least once per year, with 29.2% having recurrent falls 1
• BPPV accounts for 36.7% of chronic vestibular disorders in elderly patients 1
• Patients are particularly vulnerable between diagnosis and definitive treatment 1
• Consider activity restrictions and home supervision until BPPV resolves 1

High-Risk Features Requiring Additional Evaluation

Assess for modifying factors that affect management: impaired mobility/balance, CNS disorders, lack of home support, and increased fall risk. 1

Atypical symptoms warrant further evaluation for concurrent vestibular or CNS disorders: 1

• Subjective hearing loss 1
• Gait disturbance 1
• Non-positional vertigo 1
• Persistent nausea/vomiting after BPPV resolution 1

Post-Traumatic Dizziness

Post-traumatic BPPV requires repeated treatments in up to 67% of cases (versus 14% for non-traumatic BPPV) and may be bilateral. 1

When Pharmacologic Treatment Is Appropriate

Meclizine (12.5-25 mg) is FDA-approved for vertigo associated with vestibular system diseases, but should be reserved for acute vestibular neuritis or labyrinthitis—NOT for BPPV. 8

Important prescribing considerations 8:

• May cause drowsiness; caution with driving or operating machinery 8
• Use with care in patients with asthma, glaucoma, or prostate enlargement due to anticholinergic effects 8
• Avoid coadministration with other CNS depressants including alcohol 8
• Long-term use interferes with vestibular compensation and should be avoided 7