What are the causes and medications for dizziness in a patient with potential inner ear disorders, medication side effects, cardiovascular issues, or neurological conditions?

Causes and Medications for Dizziness

Primary Causes by Clinical Category

Dizziness should be immediately categorized by timing and triggers rather than vague patient descriptions, as this determines the underlying cause and guides management. 1, 2, 3

Brief Episodic Vertigo (Seconds to Minutes)

• Benign Paroxysmal Positional Vertigo (BPPV) is the most common cause, triggered by head position changes and lasting less than 1 minute per episode 1, 2
• Diagnosed with the Dix-Hallpike maneuver showing 5-20 second latency, torsional upbeating nystagmus toward the affected ear, and symptoms resolving within 60 seconds 1, 2

Acute Persistent Vertigo (Days to Weeks)

• Vestibular neuritis presents with constant vertigo, nausea, and vomiting without hearing loss 2, 3
• Labyrinthitis includes hearing loss in addition to vertigo symptoms 4
• Posterior circulation stroke is the most dangerous cause—critically, 75-80% of patients have NO focal neurologic deficits, so normal exam does not exclude stroke 1, 3

Spontaneous Episodic Vertigo (Minutes to Hours)

• Vestibular migraine presents with headache, photophobia, and phonophobia; extremely common but under-recognized in young patients 1, 2
• Ménière's disease characterized by fluctuating hearing loss, tinnitus, and aural fullness 1, 2, 3

Chronic Vestibular Syndrome (Weeks to Months)

• Medication side effects are the leading reversible cause—review antihypertensives, sedatives, anticonvulsants, and psychotropic drugs 1, 2, 3
• Anxiety and panic disorder cause persistent non-specific dizziness 1, 2
• Posttraumatic vertigo follows head trauma with persistent symptoms 1, 2

Other Important Causes

• Orthostatic hypotension causes presyncope with position changes 4, 5
• Cardiovascular disease including arrhythmias and valvular disease 3, 6
• Diabetic neuropathy and Parkinson disease cause disequilibrium 4

Critical Red Flags Requiring Urgent Evaluation

Any of these findings mandate immediate MRI brain without contrast and neurologic consultation: 1, 2, 3

• Focal neurological deficits (dysarthria, diplopia, numbness, weakness)
• Sudden unilateral hearing loss
• Inability to stand or walk
• Downbeating or other central nystagmus patterns
• New severe headache accompanying dizziness
• Progressive neurologic symptoms

Essential Physical Examination

The HINTS examination (Head Impulse, Nystagmus, Test of Skew) has 100% sensitivity for detecting posterior circulation stroke when performed by trained practitioners, superior to early MRI (46% sensitivity). 1, 2, 3

• Perform Dix-Hallpike maneuver for all patients with brief episodic positional symptoms 1, 2, 3
• Complete neurologic examination including cranial nerves, cerebellar testing, and gait assessment for all patients 2, 3
• Orthostatic blood pressure testing for presyncope symptoms 4, 5

Medications for Dizziness

When Medications Are NOT Indicated

For BPPV, medications are unnecessary—canalith repositioning procedures (Epley maneuver) are first-line treatment with 80% success after 1-3 treatments and 90-98% after repeat maneuvers. 1, 2, 3

When Medications ARE Indicated

Meclizine is FDA-approved for treatment of vertigo associated with vestibular system diseases in adults 7

• Use for symptomatic relief in vestibular neuritis or labyrinthitis
• Not indicated for BPPV

For Ménière's Disease: 1, 3

• Salt restriction and diuretics as first-line management
• Intratympanic dexamethasone or gentamicin for refractory cases 4

For Vestibular Migraine: 1, 2, 3

• Migraine prophylaxis medications
• Lifestyle modifications

For Orthostatic Hypotension: 4

• Alpha agonists
• Mineralocorticoids (fludrocortisone—note that vertigo is listed as an adverse effect, so use cautiously) 8
• Lifestyle changes including increased fluid and salt intake

For Vestibular Neuritis: 2, 3

• Steroids may be beneficial
• Vestibular rehabilitation therapy should be initiated as soon as possible

For Anxiety/Panic Disorder: 1, 2

• Psychiatric treatment and cognitive behavioral therapy

Imaging Decisions

No imaging is indicated for: 1, 2, 3

• Brief episodic vertigo with typical BPPV features and positive Dix-Hallpike
• Acute persistent vertigo with normal neurologic exam and HINTS consistent with peripheral vertigo (by trained examiner)

MRI brain without contrast (with diffusion-weighted imaging) is indicated for: 1, 2, 3

• Abnormal neurologic examination
• HINTS examination suggesting central cause
• High vascular risk patients with acute vestibular syndrome
• Unilateral or pulsatile tinnitus
• Asymmetric hearing loss
• Any red flag symptoms listed above

CT head has only 20-40% sensitivity for posterior circulation infarcts and should NOT be used instead of MRI when stroke is suspected. 1, 2

Common Pitfalls to Avoid

• Never rely on patient's description of "spinning" versus "lightheadedness"—focus on timing and triggers instead 1, 2, 3
• Never assume normal neurologic exam excludes stroke—75-80% of posterior circulation strokes have no focal deficits 1, 2, 3
• Never order imaging for straightforward BPPV with positive Dix-Hallpike—this delays effective treatment 1, 2
• Never skip the Dix-Hallpike maneuver—it is the gold standard diagnostic test 1, 2
• Never overlook vestibular migraine—it is extremely common but under-recognized, especially in young patients 2
• Never use CT instead of MRI when stroke is suspected—CT misses most posterior circulation infarcts 1, 2