What are the management and treatment options for a patient experiencing dizziness?

Management of Dizziness

For a patient presenting with dizziness, immediately classify the symptom by timing and triggers rather than the patient's subjective description, then perform the Dix-Hallpike maneuver if episodes are brief and positional, or the HINTS examination if vertigo is acute and persistent—this approach determines whether you're dealing with benign peripheral causes requiring repositioning maneuvers or dangerous central pathology requiring urgent imaging. 1, 2

Initial Diagnostic Approach

Classify by Timing Pattern (Not Patient Description)

The patient's description of "spinning" versus "lightheadedness" is unreliable and should not guide your evaluation. 2 Instead, categorize dizziness into one of these temporal patterns:

• Brief episodic vertigo: Seconds to minutes, triggered by head movements—think BPPV 2
• Acute persistent vertigo: Days to weeks of constant symptoms—consider vestibular neuritis or stroke 2
• Spontaneous episodic vertigo: Recurrent episodes without positional triggers—suspect vestibular migraine or Ménière's disease 2
• Chronic vestibular syndrome: Weeks to months of persistent symptoms—evaluate for medication effects, anxiety, or incomplete compensation 3, 2

Critical History Elements

Focus on these specific details rather than vague descriptions:

• Duration of each episode: Seconds suggests BPPV, minutes to hours suggests Ménière's or migraine, days suggests neuritis 2, 4
• Specific triggers: Head position changes (BPPV), loud sounds (superior canal dehiscence), stress/sleep deprivation (vestibular migraine) 2
• Associated symptoms: Hearing loss, tinnitus, or aural fullness strongly suggest Ménière's disease 2, 4
• Headache with photophobia/phonophobia: Points to vestibular migraine 2
• Medication review: Antihypertensives, sedatives, anticonvulsants, and psychotropic drugs are leading reversible causes of chronic dizziness 3, 2

Physical Examination Protocol

For Brief Episodic Vertigo (Suspected BPPV)

Perform the Dix-Hallpike maneuver as your gold standard diagnostic test. 1, 2 Positive findings include:

• Latency period of 5-20 seconds before symptoms begin 2
• Torsional, upbeating nystagmus toward the affected ear 2
• Vertigo and nystagmus that increase then resolve within 60 seconds 2

If the Dix-Hallpike is negative but history suggests BPPV, perform the supine roll test to assess for lateral semicircular canal BPPV. 1

For Acute Persistent Vertigo (Suspected Stroke vs. Neuritis)

Perform the HINTS examination (Head-Impulse, Nystagmus, Test of Skew) if you are trained in this technique—it has 100% sensitivity for detecting stroke versus 46% for early MRI. 2 However, recognize that HINTS performed by non-experts is unreliable and should not be used to exclude stroke. 2

Critical warning: 75-80% of patients with posterior circulation stroke have NO focal neurologic deficits, so a normal neurologic exam does not exclude stroke. 2

Additional Examination Components

• Orthostatic blood pressure measurement 4, 5
• Full cardiac and neurologic examination 4, 5
• Assessment for nystagmus patterns 4, 5

When to Order Imaging

Do NOT Order Imaging For:

• 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 a trained examiner 2
• Straightforward BPPV meeting diagnostic criteria 2

Routine imaging for isolated dizziness has a diagnostic yield under 1% with CT and only 4% with MRI. 2

Order MRI Brain Without Contrast For:

• 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
• Progressive symptoms suggesting mass lesion 2
• New severe headache accompanying dizziness (requires immediate imaging and neurologic consultation) 2

Never use CT instead of MRI when stroke is suspected—CT misses most posterior circulation infarcts. 2

Treatment Based on Diagnosis

BPPV (Most Common Cause)

Treat with canalith repositioning procedures (Epley maneuver) as first-line therapy—this achieves 80% success after 1-3 treatments and 90-98% after repeat maneuvers. 1, 3, 2 The Epley maneuver shows 80% vertigo resolution at 24 hours versus 13% with sham treatment. 3

For lateral canal BPPV:

• Geotropic type: Use barbecue roll maneuver or Gufoni maneuver (81% vs 93% success respectively) 1
• Apogeotropic type: Use modified Gufoni maneuver 1

Do NOT prescribe vestibular suppressant medications routinely for BPPV—the guideline makes a strong recommendation against antihistamines or benzodiazepines. 1 Patients who received repositioning maneuvers alone recovered faster than those given concurrent vestibular suppressants. 3

Persistent Dizziness After Initial Treatment

Vestibular rehabilitation therapy is the primary intervention for persistent dizziness that has failed initial treatment, significantly improving gait stability compared to medication alone. 3 This is especially indicated when balance and motion tolerance do not improve within a few days to weeks. 3

Vestibular rehabilitation includes:

• Habituation exercises 3
• Gaze stabilization 3
• Balance retraining 3
• Fall prevention strategies 3

Medication Considerations (Use Sparingly)

Meclizine hydrochloride is FDA-approved for vertigo associated with vestibular system diseases at 25-100 mg daily in divided doses, but should only be used for short-term management of severe acute symptoms. 6, 3

Critical warnings about vestibular suppressants:

• Long-term use interferes with central compensation and can prolong symptoms 3
• All vestibular suppressants cause drowsiness, cognitive deficits, and significantly increase fall risk, especially in elderly patients 3
• Benzodiazepines are an independent risk factor for falls and should be discontinued 3
• In frail elderly or those with limited life expectancy, meclizine is considered eligible for deprescribing 3

Betahistine (16-48 mg three times daily) may be effective in specific subgroups (patients over 50 with hypertension and symptom onset <1 month), but recent high-quality trials show no significant difference between betahistine and placebo. 3

Ménière's Disease

• Salt restriction 4, 5
• Diuretics 4, 5
• For persistent symptoms: Consider intratympanic steroid therapy 3

Vestibular Migraine

• Migraine prophylaxis 2
• Lifestyle modifications 2

Red Flags Requiring Urgent Evaluation

These findings mandate immediate imaging and specialist consultation:

• Focal neurological deficits 2
• Sudden hearing loss 2
• Inability to stand or walk 2
• Downbeating nystagmus or other central nystagmus patterns 2
• New severe headache 2
• Failure to respond to appropriate vestibular treatments 2

Follow-Up Protocol

Reassess all patients within 1 month after initial treatment to document resolution or persistence of symptoms. 1, 3 At this visit:

• Confirm symptom resolution or identify persistent BPPV 1
• Evaluate for underlying peripheral vestibular or CNS disorders if treatment failed 1
• Detect atypical symptoms (hearing loss, gait disturbance, non-positional vertigo) warranting further evaluation 3

Counsel patients about:

• BPPV recurrence risk (10-18% at 1 year, up to 36% over time) 3
• Fall risk and home safety assessment 1, 3
• Importance of returning promptly if symptoms recur for repeat repositioning 2

Common Pitfalls to Avoid

• Do not rely on patient's description of "spinning" versus "lightheadedness"—focus on timing and triggers instead 2
• Do not assume normal neurologic exam excludes stroke—most posterior circulation strokes have no focal deficits 2
• Do not order routine imaging for isolated dizziness—yield is extremely low and most findings are incidental 2
• Do not prescribe vestibular suppressants as long-term therapy—they impede compensation 3
• Do not fail to perform appropriate positional testing—this is how you diagnose BPPV 2
• Do not overlook medication review—this is one of the most common and reversible causes of chronic dizziness 3, 2