From the Guidelines
Dizziness after a stroke should be managed with a combination of medications, rehabilitation, and lifestyle modifications to minimize symptoms and prevent falls, as recommended by the most recent guidelines 1. To manage dizziness after a stroke, it is essential to consult a healthcare provider who may prescribe medications like meclizine, diazepam, or promethazine to alleviate symptoms. Vestibular rehabilitation therapy is also recommended, which typically involves exercises to help the brain compensate for balance issues, and should be performed daily for 15-20 minutes under the guidance of a physical therapist 1. Some key strategies to minimize dizziness episodes include:
- Staying hydrated
- Avoiding sudden head movements
- Rising slowly from sitting or lying positions
- Removing tripping hazards and ensuring a clear walking path
- Providing adequate lighting
- Wearing shoes with nonskid soles
- Slowing down movements for transfers or walking The dizziness occurs because strokes can damage areas of the brain responsible for balance and spatial orientation, particularly when they affect the cerebellum, brainstem, or vestibular pathways 1. While dizziness often improves over time as the brain recovers and compensates, some patients may experience persistent symptoms requiring ongoing management. If dizziness worsens suddenly or is accompanied by new symptoms like severe headache, vision changes, or increased weakness, it is crucial to seek immediate medical attention as this could indicate a new stroke or other serious complication 1. The interdisciplinary rehabilitation team should work together to identify individual risk factors for falls and environmental hazards and address those with the stroke survivor and caregiver, as falls are a significant concern in post-stroke patients, with 37% of post-stroke individuals falling within 6 months 1.
From the Research
Causes of Dizziness after Stroke
- Dizziness after stroke can be caused by various factors, including orthostatic hypotension, vestibular disorders, and psychiatric disorders such as depression and anxiety 2, 3, 4.
- Orthostatic hypotension is a common condition in stroke patients, affecting about one quarter of outpatients with stroke, and is associated with an increased risk of falls and mortality 2.
- Vestibular disorders, such as benign paroxysmal positional vertigo, Meniere disease, and vestibular neuritis, can also cause dizziness after stroke 5.
Diagnosis and Evaluation
- The diagnosis of dizziness after stroke requires a thorough evaluation, including a physical examination, orthostatic blood pressure measurement, and assessment for nystagmus and other vestibular function tests 5.
- The HINTS (head-impulse, nystagmus, test of skew) examination can help distinguish peripheral from central etiologies of dizziness 5.
- Laboratory testing and imaging are not always required and are usually not helpful in diagnosing the cause of dizziness after stroke 5.
Treatment and Management
- The treatment of dizziness after stroke depends on the underlying cause, and may include vestibular rehabilitation therapy, medication, and targeted treatments for psychiatric disorders such as depression and anxiety 4.
- Addressing psychological factors such as depression and anxiety may alleviate dizziness symptoms, and improving vestibular function may also mitigate secondary symptoms like anxiety and depression 4.
- A combination of fludrocortisone, a pressor agent (midodrine or droxidopa), and procedures to improve orthostatic defenses may be used to manage orthostatic hypotension 3.