What is the approach to diagnosis and management of dizziness in patients, particularly the elderly or those with a history of falls, considering various underlying conditions and medications?

Dizziness Algorithm for Diagnosis and Management

Initial Classification by Timing and Triggers

Classify every dizzy patient into one of three vestibular syndromes based on timing and triggers, not symptom quality, as this approach distinguishes benign peripheral causes from dangerous central causes like stroke. 1, 2

The Three Key Categories:

• Acute Vestibular Syndrome (AVS): Continuous dizziness lasting days, with sudden onset and persistent symptoms 1, 2
• Spontaneous Episodic Vestibular Syndrome: Recurrent episodes without positional triggers, lasting minutes to hours 1, 2
• Triggered Episodic Vestibular Syndrome: Brief episodes provoked by specific head movements or position changes 1, 2

Priority Assessment Questions (Ask in This Order)

For elderly patients and those with fall history, immediately screen for fall risk before proceeding with diagnostic workup. 3, 1

Critical History Elements:

• Age and history of previous falls 1
• Duration of episodes (seconds, minutes, hours, or days) 3, 1
• Specific triggers (head movement, standing, none) 1, 2
• Time spent on floor/ground after any fall 1
• Loss of consciousness or altered mental status 1
• Near-syncope or orthostatic symptoms 3, 1
• Associated symptoms: hearing loss, tinnitus, ear fullness, headache, neurologic deficits 3, 1
• Feeling unsteady when standing or walking 3, 1
• Worry about falling 3, 1

Physical Examination Protocol

For Triggered Episodic Vestibular Syndrome (Suspected BPPV):

Perform the Dix-Hallpike maneuver immediately—this is diagnostic and therapeutic planning depends on the result. 3, 4

• Positive test shows brief latency nystagmus that increases then decreases (fatigable) 4
• If positive: proceed directly to Epley maneuver 1, 4
• No imaging needed for typical BPPV with positive Dix-Hallpike and normal neurologic exam 1, 4

For Acute Vestibular Syndrome:

Use the HINTS examination (Head-Impulse, Nystagmus, Test of Skew) to differentiate peripheral vestibular neuritis from posterior circulation stroke—this is more sensitive than early MRI. 1, 5

• Normal head impulse test, direction-changing nystagmus, or skew deviation suggests central (stroke) cause 1
• Abnormal head impulse test, unidirectional nystagmus, and no skew deviation suggests peripheral cause 1

For All Patients:

• Assess for nystagmus at rest 6, 5
• Orthostatic blood pressure measurement (0-30 seconds for initial OH, 30 seconds-3 minutes for classical OH, 3-30 minutes for delayed OH) 3
• Full neurologic examination looking for dysarthria, dysmetria, dysphagia, sensory/motor loss, Horner's syndrome 3

Fall Risk Stratification (Mandatory for Elderly)

Among elderly patients with undiagnosed BPPV, 75% had fallen within 3 months—fall risk assessment is not optional. 3, 1

Screening Questions:

• Have you fallen in the past year? How many times? Were you injured? 3, 1
• Do you feel unsteady when standing or walking? 3, 1
• Do you worry about falling? 3, 1

If Any Positive Response, Use Formal Assessment:

• Get Up and Go test 3, 1
• Tinetti Balance Assessment 3, 1
• Berg Balance Scale 3, 1

Imaging Decision Algorithm

NO Imaging Required:

• Brief episodic vertigo with typical BPPV features and positive Dix-Hallpike 1
• Acute persistent vertigo with normal neurologic exam and HINTS consistent with peripheral vertigo by trained examiner 1

MRI Brain (Without Contrast) Required:

• Abnormal neurologic examination 1
• HINTS examination suggesting central cause 1
• High vascular risk patients with acute vestibular syndrome 1
• Unilateral or pulsatile tinnitus 1
• Asymmetric hearing loss 1
• Atypical symptoms or no response to treatment 4

Immediate Management by Diagnosis

BPPV (Most Common):

Perform the Epley maneuver immediately—success rate is 90-98% and delays only prolong disability. 1, 4

• Reassess within 1 month to document resolution or persistence 3
• Post-traumatic BPPV has higher recurrence (up to 67%) and may require repeated treatments 4
• Consider vestibular rehabilitation for persistent symptoms 4

Suspected Posterior Circulation Stroke:

Activate stroke protocol immediately and obtain urgent neurology consultation. 1

Ménière's Disease:

• Diagnosed by 2+ episodes of vertigo lasting 20 minutes to 24 hours with fluctuating hearing loss, tinnitus, or ear fullness 3
• Consider audiogram, video/electronystagmogram, electrocochleography, or MRI brain for diagnosis 3

Orthostatic Hypotension:

• Treat underlying cause (medication adjustment, volume repletion) 3, 6
• Consider alpha agonists or mineralocorticoids for refractory cases 6

Medication Management

Vestibular Suppressants—Use Extreme Caution:

Vestibular suppressants are NOT routinely recommended for BPPV and significantly increase fall risk, especially in elderly patients taking multiple medications. 3

Limited Indications Only:

• Short-term management of severe nausea/vomiting in acutely symptomatic patients 3
• Patients who refuse canalith repositioning procedures 3
• Prophylaxis before Dix-Hallpike in patients with prior severe nausea/vomiting 3

Meclizine (If Prescribed):

• FDA-approved for vertigo associated with vestibular system diseases 7
• Dosage: 25-100 mg daily in divided doses 7
• Warning: Causes drowsiness, cognitive deficits, and increases fall risk—use with extreme caution in elderly 7
• Contraindicated in hypersensitivity; use carefully with asthma, glaucoma, or prostate enlargement 7

Critical Counseling When Prescribing Vestibular Suppressants:

Counsel patients that cognitive dysfunction, falls, drug interactions, and driving/machinery accidents increase with vestibular suppressant use. 3

Safety Assessment Before Discharge

Patients must demonstrate three capabilities before discharge to prevent falls. 1

Required Demonstrations:

• Ability to rise from bed independently 1
• Steady ambulation out of examination area 1
• Understanding of fall precautions 1

Specific Fall Precautions to Teach:

• Sit or lie down immediately when feeling dizzy 1
• Use assistive devices if balance affected 1
• Avoid driving during acute episodes 1
• Implement home safety modifications 1

Common Pitfalls to Avoid

Do not rely on patient descriptions of "vertigo" vs "lightheadedness"—these terms are inconsistent and do not distinguish benign from dangerous causes. 2, 5

• The traditional symptom-quality approach (vertigo, presyncope, disequilibrium, lightheadedness) is outdated and leads to misdiagnosis 2
• Timing and triggers are far more diagnostically useful than symptom descriptions 1, 2
• Approximately 20% of cases remain undiagnosed despite thorough evaluation 6
• Dizziness accounts for 12-fold increased fall risk in symptomatic older individuals 3
• Benzodiazepines are independent risk factors for falls—avoid in elderly dizzy patients 3