What are the potential causes and treatment options for a patient experiencing dizzy spells, considering their age, medical history, and current medications, such as antihypertensives (blood pressure medications) or sedatives?

Causes of Dizzy Spells

Dizzy spells in adults stem from four distinct categories that require different evaluations: orthostatic hypotension (especially in elderly patients on multiple medications), peripheral vestibular disorders (BPPV, Ménière's disease, vestibular neuritis), vestibular migraine, and cardiac syncope—with the specific cause determined by timing, triggers, and associated symptoms rather than the patient's subjective description of "dizziness." 1

Critical First Step: Categorize by Timing and Triggers, Not Patient Description

• Do not rely on patient descriptions of "spinning" versus "lightheadedness"—instead, classify dizziness into one of four vestibular syndromes based on timing: acute vestibular syndrome (continuous for days), triggered episodic (seconds with position change), spontaneous episodic (minutes to hours without trigger), or chronic vestibular syndrome (persistent for weeks) 2, 1

• The American Heart Association emphasizes that categorizing by timing rather than subjective description is the most reliable diagnostic approach 2

Age-Specific Considerations: The Elderly Patient

In elderly patients, dizzy spells are frequently multifactorial and often medication-related, requiring immediate assessment of polypharmacy, orthostatic vital signs, and cardiovascular causes. 3

Age-Related Physiological Changes

• Elderly patients have reduced thirst perception, impaired sodium and water preservation, diminished baroreceptor response, and blunted heart rate response to orthostatic stress—all predisposing to orthostatic hypotension and syncope 3

• Up to 30% of falls in the elderly are due to syncope, with marked clinical overlap between falls, orthostatic hypotension, and dizzy spells 3

Medication-Induced Dizziness (Critical Pitfall)

• Common culprits include diuretics, β-blockers, calcium antagonists, ACE inhibitors, nitrates, antipsychotic agents, tricyclic antidepressants, antihistamines, dopamine agonists/antagonists, and narcotics—all of which precipitate syncope, especially when combined with age-related loss of peripheral autonomic tone 3

• Tricyclic antidepressants, nitrates, and antiparkinsonian medications specifically induce orthostatic hypotension through dysautonomia 3

Primary Causes by Category

1. Orthostatic Hypotension and Cardiovascular Causes

• Perform bedside orthostatic vital signs testing (blood pressure and heart rate supine, then after 1 and 3 minutes of standing) to identify orthostatic hypotension, which can result from medications, autonomic dysfunction, or volume depletion 3, 1

• Cardiac syncope should be suspected when dizzy spells occur with exertion, are preceded by palpitations, or occur in patients with known structural heart disease 3

• Carotid sinus hypersensitivity is particularly relevant in elderly patients and should be considered when other causes are excluded 3

2. Peripheral Vestibular Disorders

Benign Paroxysmal Positional Vertigo (BPPV):

• Brief episodes (seconds) of vertigo triggered by specific head movements or position changes 2, 1
• Diagnose with Dix-Hallpike maneuver and supine roll test—failure to perform these tests when positional symptoms are present is a common pitfall 2, 1

Ménière's Disease:

• Episodic vertigo lasting 20 minutes to 12 hours, accompanied by fluctuating hearing loss, tinnitus, and aural fullness 3, 2, 1
• The American Academy of Otolaryngology-Head and Neck Surgery emphasizes that loss of consciousness never occurs with Ménière's disease 3

Vestibular Neuritis/Labyrinthitis:

• Acute vestibular syndrome with continuous symptoms lasting days, often following viral illness 1, 4

3. Vestibular Migraine (Commonly Missed Diagnosis)

• The American Academy of Otolaryngology-Head and Neck Surgery mandates determining if patients meet diagnostic criteria for vestibular migraine when assessing dizzy spells, as this condition closely mimics Ménière's disease 3, 2

• Vestibular migraine presents with ≥5 episodes of moderate-to-severe vestibular symptoms lasting 5 minutes to 72 hours, with migraine features (headache, photophobia, phonophobia, visual aura) in ≥50% of episodes 2

• Unlike Ménière's disease, vestibular migraine may have short (<15 minutes) or prolonged (>24 hours) episodes, hearing loss is mild or absent and stable over time, and motion intolerance with light sensitivity is prominent 3, 2

4. Neurological Causes (Rare but Critical)

• Cerebrovascular disease causes syncope only with severe bilateral carotid or basilar artery disease and rarely occurs without focal neurological signs (diplopia, limb weakness, sensory deficits, speech difficulties) 3

• Syncope in the supine position, preceded by an aura, or followed by confusion/amnesia suggests a neurological disorder requiring urgent evaluation 3

• Disorders increasing intracranial pressure (subarachnoid hemorrhage, brain tumors) can result in true syncope but are rare 3

Red Flags Requiring Urgent Evaluation

• Focal neurological deficits (diplopia, dysarthria, numbness, weakness) require immediate neuroimaging 2, 1
• Sudden hearing loss demands urgent otolaryngology referral 1
• Inability to stand or walk suggests acute vestibular syndrome requiring HINTS examination to exclude stroke 2, 1
• The American Heart Association warns that 75-80% of patients with posterior circulation stroke from acute vestibular syndrome have no focal neurologic deficits, so a normal neurologic exam does not exclude stroke 2

Diagnostic Approach Algorithm

1. Obtain orthostatic vital signs in all patients, especially elderly and those on antihypertensives 3, 1

2. Perform Dix-Hallpike maneuver and supine roll test if symptoms are triggered by position changes 2, 1

3. Assess for nystagmus and perform complete otologic examination including vestibular testing 1

4. Inquire specifically about migraine history, including motion intolerance, light sensitivity, and visual auras 3, 2

5. Review medication list systematically for drugs causing orthostatic hypotension or vestibular suppression 3

6. Laboratory testing (basic metabolic panel, complete blood count, thyroid function) only if dehydration, electrolyte abnormalities, infection, or thyroid disorder is suspected 1

7. Imaging is NOT routinely indicated unless abnormal neurological examination, HINTS examination suggests central cause, or high vascular risk with acute vestibular syndrome 2, 1

Treatment Considerations

• For peripheral vestibular disorders: Epley maneuver (canalith repositioning) for BPPV, vestibular rehabilitation, intratympanic dexamethasone or gentamicin for Ménière's disease, and steroids for vestibular neuritis 5, 4

• Meclizine hydrochloride is FDA-approved for vertigo associated with vestibular system diseases at doses of 25-100 mg daily in divided doses, though it causes drowsiness and has anticholinergic effects 6

• For orthostatic hypotension: Alpha agonists, mineralocorticoids, or lifestyle modifications (increased fluid/salt intake, compression stockings, slow positional changes) 5

• For vestibular migraine: Migraine prophylaxis and acute migraine treatment 2

Common Pitfalls to Avoid

• Do not dismiss dizzy spells as benign without systematic evaluation, especially in elderly patients where multiple causes frequently coexist 3

• Do not confuse visual distortion (metamorphopsia) with vestibular symptoms—metamorphopsia indicates macular disease requiring urgent ophthalmology referral 7

• Do not prescribe chronic vestibular suppressive medications (meclizine, antihistamines, benzodiazepines) without a specific diagnosis, as they delay central compensation and worsen long-term outcomes 6, 8

• Do not assume normal neurologic exam excludes stroke in patients with acute vestibular syndrome—HINTS examination is more sensitive than early MRI 2