What are the initial treatment steps for a patient experiencing dizziness?

Initial Treatment Steps for Dizziness

The initial treatment for dizziness depends entirely on identifying the specific timing pattern and triggers through focused history, followed by targeted physical examination—not on the patient's vague description of symptoms. 1

Step 1: Classify Dizziness by Timing and Triggers (Not Patient Description)

Do not rely on patient descriptions of "spinning" versus "lightheadedness"—these are unreliable. 1 Instead, immediately classify into one of these categories:

• Brief episodic (seconds to minutes) triggered by head movements → Likely BPPV 1
• Acute persistent (days to weeks) with constant symptoms → Peripheral vestibular disorder or stroke 1
• Spontaneous episodic without clear triggers → Vestibular migraine or Ménière's disease 1
• Chronic (weeks to months) → Medication side effects, anxiety, or central pathology 1

Step 2: Perform Targeted Physical Examination Based on Classification

For Brief Episodic Dizziness (Suspected BPPV):

Perform the Dix-Hallpike maneuver immediately—this is both diagnostic and guides treatment. 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 Dix-Hallpike is positive: Proceed directly to treatment with canalith repositioning (Epley maneuver)—no imaging or laboratory testing is needed. 1, 3 Success rate is 80% after 1-3 treatments and 90-98% after repeat maneuvers. 3

For Acute Persistent Dizziness:

Perform the HINTS examination (Head Impulse, Nystagmus, Test of Skew) if you are trained—it has 100% sensitivity for detecting posterior circulation stroke versus 46% for early MRI. 1, 4

Critical warning: If you are not trained in HINTS, do not rely on it—non-expert performance is unreliable. 1

Check for red flags requiring immediate MRI and neurology consultation: 1, 3

• Focal neurological deficits
• Sudden hearing loss
• Inability to stand or walk independently
• New severe headache
• Downbeating nystagmus

If patient has high vascular risk (age >50, hypertension, diabetes, prior stroke) with acute vestibular syndrome, obtain MRI brain without contrast even with normal neurologic exam—11-25% may have posterior circulation stroke. 1

Step 3: Initiate Specific Treatment Based on Diagnosis

BPPV (Most Common):

Perform Epley maneuver immediately in the office—do not prescribe medications. 2, 1, 3 Vestibular suppressants like meclizine have only 30.8% success rate compared to 78.6-93.3% for repositioning maneuvers. 3

For lateral canal BPPV, use barbecue roll maneuver or Gufoni maneuver with 81-93% success rates. 2

Medication-Induced Dizziness (Leading Cause of Chronic Dizziness):

Review and reduce/discontinue antihypertensives, sedatives, anticonvulsants, and psychotropic drugs. 1 This is particularly important in heart failure patients on guideline-directed medical therapy (GDMT). 2

In heart failure patients with low blood pressure and mild dizziness: Do not down-titrate GDMT if patient is clinically stable—educate patient that transient dizziness is a side effect of life-prolonging drugs. 2 Instead, assess for congestion and consider cautious diuretic reduction if no congestive signs present. 2

Vestibular Neuritis/Labyrinthitis:

Limit vestibular suppressants to 2-3 days maximum—they impede central compensation. 4 Initiate vestibular rehabilitation therapy early. 1

Vestibular Migraine:

Initiate migraine prophylaxis and lifestyle modifications. 1

Ménière's Disease:

Start salt restriction and diuretics; consider intratympanic treatments for refractory cases. 1

Step 4: Determine Need for Imaging

Do not order imaging for: 1

• Brief episodic vertigo with positive Dix-Hallpike test and no red flags
• Acute persistent vertigo with normal neurologic exam and peripheral HINTS findings (by trained examiner)
• Isolated nonspecific dizziness without vertigo, ataxia, or neurologic deficits (CT yield <1%, MRI yield only 4%) 2

Order MRI brain without contrast (NOT CT) for: 1, 4

• Abnormal neurologic examination
• HINTS examination suggesting central cause
• High vascular risk patients with acute vestibular syndrome
• Unilateral or pulsatile tinnitus
• Asymmetric hearing loss
• Progressive symptoms suggesting mass lesion

Critical pitfall: CT head has very low sensitivity (20-40%) for posterior circulation infarcts and should not be used when stroke is suspected. 1, 4

Step 5: Arrange Follow-Up and Patient Education

Reassess within 1 month (or 1 week for acute vestibular syndrome) to document resolution or persistence. 2, 4

Counsel patients about: 2, 3

• Fall risk during symptomatic periods—balance will be "off"
• BPPV recurrence risk: 10-18% at 1 year, up to 36% long-term
• Importance of returning promptly if symptoms recur for repeat repositioning
• Gradual return to normal activities to speed healing

For persistent symptoms after initial treatment, initiate vestibular rehabilitation therapy—this significantly improves gait stability, particularly in elderly patients or those with heightened fall risk. 1