What is the best approach to manage giddiness?

Approach and Management of Giddiness

For giddiness (dizziness/vertigo), immediately classify the presentation by timing pattern—acute prolonged, recurrent spontaneous, positional, or chronic—then perform targeted bedside testing (Dix-Hallpike for positional symptoms, HINTS exam for acute prolonged vertigo) to guide specific treatment, with canalith repositioning procedures as first-line for BPPV and avoidance of vestibular suppressant medications except for severe nausea. 1, 2

Initial Classification by Timing Pattern

The first critical step is determining the temporal pattern, which narrows the differential diagnosis dramatically:

• Acute prolonged spontaneous vertigo (continuous for hours to days): Consider vestibular neuritis versus stroke—this requires immediate HINTS examination to differentiate peripheral from central causes 2
• Recurrent spontaneous episodes: Think Ménière's disease (20 minutes to hours with hearing loss), vestibular migraine (minutes to days), or vertebrobasilar insufficiency (typically <30 minutes in older adults with vascular risk factors) 3, 4
• Recurrent positional vertigo (triggered by head position changes): BPPV is the most likely diagnosis, requiring Dix-Hallpike or supine roll testing 1, 2
• Chronic persistent dizziness: Consider multiple etiologies including inadequately treated BPPV, vestibular compensation failure, or cervical vertigo 3, 5

Bedside Diagnostic Testing

For Positional Symptoms (Suspected BPPV)

• Dix-Hallpike maneuver: Diagnoses posterior canal BPPV (85-95% of cases) by provoking torsional upbeating nystagmus when bringing patient from upright to supine with head turned 45° and neck extended 20° 1
• Supine roll test: Diagnoses horizontal canal BPPV (10-15% of cases) by rapidly turning the head 90° to each side while supine, observing for horizontal nystagmus 1
• Key distinguishing feature: BPPV nystagmus fatigues with repeated testing and is suppressed by visual fixation, unlike central causes 3

For Acute Prolonged Vertigo (Suspected Stroke vs. Vestibular Neuritis)

The HINTS examination is more sensitive than brain imaging for detecting stroke presenting as acute vertigo 2:

• Head Impulse test: Abnormal (corrective saccade) suggests peripheral; normal suggests central/stroke 6
• Nystagmus pattern: Pure torsional or vertical nystagmus suggests central; horizontal nystagmus that changes direction with gaze suggests central 3
• Test of Skew: Vertical misalignment suggests central cause 6

Treatment Algorithm by Diagnosis

BPPV (Most Common Cause)

Canalith repositioning procedures are 10 times more effective than exercises and should be performed immediately without medications or imaging 1:

• Posterior canal BPPV: Epley maneuver achieves 80% resolution with 1-3 treatments, 90-98% with repeat maneuvers if needed 1

  • Patient sits upright, head turned 45° toward affected ear
  • Rapidly lay back to supine head-hanging 20° position for 20-30 seconds
  • Turn head 90° toward unaffected side, hold 20-30 seconds
  • Roll patient onto side, hold 20-30 seconds
  • Return to sitting 1

• Horizontal canal BPPV (geotropic): Barbecue Roll (Lempert) maneuver with 50-100% success rate 1

• Horizontal canal BPPV (apogeotropic): Modified Gufoni maneuver 1

Critical post-treatment instructions:

• No postprocedural restrictions—patients can resume normal activities immediately, as restrictions provide no benefit and may cause unnecessary complications 1
• Reassess within 1 month to confirm resolution 1

Medication Management: What NOT to Do

Vestibular suppressant medications (meclizine, antihistamines, benzodiazepines) should NOT be routinely prescribed for BPPV 1, 7:

• No evidence they work as definitive treatment (30.8% improvement vs. 78.6-93.3% with repositioning procedures) 5
• Cause significant adverse effects: drowsiness, cognitive deficits, increased fall risk (especially in elderly), interference with central compensation 1, 7
• Patients who received repositioning alone recovered faster than those given concurrent vestibular suppressants 7

Limited exception: Short-term use only for severe nausea/vomiting in severely symptomatic patients refusing other treatment, or as prophylaxis before repositioning in patients with previous severe nausea 1, 7

Vestibular Neuritis

• Short-term vestibular suppressants may be appropriate for acute symptomatic relief 7
• Transition to vestibular rehabilitation therapy within days to promote central compensation 5

Ménière's Disease

• Limited course of vestibular suppressants for acute attacks 7
• Dietary sodium restriction and diuretics for prevention 7
• Consider intratympanic steroid therapy for persistent symptoms 5

Vestibular Migraine

• Requires migraine prophylaxis and trigger avoidance 3
• Distinguished from BPPV by necessary migraine/headache components 3

When Treatment Fails

If symptoms persist after initial repositioning procedures, systematically evaluate for 1:

1. Persistent BPPV: Repeat diagnostic testing and perform additional repositioning (achieves 90-98% success) 1
2. Canal conversion: Occurs in 6-7% of cases—posterior canal may convert to lateral canal or vice versa 1
3. Multiple canal involvement: Rare but possible 1
4. Coexisting vestibular pathology: BPPV can occur with Ménière's disease or vestibular neuritis 3
5. Central causes masquerading as BPPV: Especially if atypical features present (gaze-evoked nystagmus, severe postural instability, neurological signs) 3, 1

Special Populations and Contraindications

Assess all patients before treatment for 1:

• Severe cervical stenosis or radiculopathy
• Severe rheumatoid arthritis or ankylosing spondylitis
• Morbid obesity
• Known cerebrovascular disease

For patients with contraindications: Consider Brandt-Daroff exercises (performed three times daily for 2 weeks) or refer to specialized vestibular physical therapy, though these are significantly less effective than repositioning procedures 1

Elderly patients warrant particular attention: BPPV increases fall risk 12-fold, and 9% of patients in geriatric clinics have undiagnosed BPPV, with three-quarters having fallen within the previous 3 months 1

Adjunctive Vestibular Rehabilitation

Vestibular rehabilitation therapy should be offered as adjunctive therapy (not substitute) for 1, 5:

• Residual dizziness after successful repositioning
• Postural instability or heightened fall risk
• Chronic persistent dizziness after multiple medication trials

VRT reduces BPPV recurrence rates by approximately 50% and significantly improves gait stability compared to repositioning alone 1, 5

Common Pitfalls to Avoid

• Don't order imaging or vestibular testing unless atypical neurological signs present (abnormal cranial nerves, severe headache, visual disturbances) 1
• Don't prescribe vestibular suppressants as primary BPPV treatment—they interfere with compensation and increase fall risk 1, 7
• Don't impose postprocedural restrictions after repositioning—no evidence of benefit 1
• Don't assume single diagnosis—consider concurrent vestibular disorders if patient doesn't clearly fit one entity 3
• Don't miss central causes: Vertebrobasilar insufficiency nystagmus doesn't fatigue and isn't suppressed by gaze fixation, unlike BPPV 3