What is the appropriate management for a patient experiencing dizziness?

Management of Dizziness

The appropriate management of dizziness depends on categorizing the presentation by timing and triggers rather than vague patient descriptions, with the Dix-Hallpike maneuver and canalith repositioning procedures (Epley maneuver) as first-line for benign paroxysmal positional vertigo (BPPV), while avoiding routine vestibular suppressant medications. 1, 2

Initial Clinical Assessment: Timing and Triggers

Focus your evaluation on timing patterns rather than the patient's subjective description of "spinning" versus "lightheadedness," which are unreliable. 1, 2

Categorize dizziness into four vestibular syndromes: 1

• Brief episodic (seconds to <1 minute): Triggered by head position changes → suggests BPPV (most common, 42% of all vertigo cases) 2
• Acute persistent (days to weeks): Constant symptoms → suggests vestibular neuritis, labyrinthitis, or posterior circulation stroke 1, 2
• Spontaneous episodic (minutes to hours): No positional trigger → suggests vestibular migraine (14% of cases, often under-recognized) or Ménière's disease 2
• Chronic (weeks to months): Consider medication side effects (leading reversible cause), anxiety/panic disorder, or posttraumatic vertigo 2

Key history elements to elicit: 1, 2

• Duration: Seconds (BPPV), minutes-hours (vestibular migraine/Ménière's), days-weeks (vestibular neuritis/stroke) 2
• Triggers: Positional changes, standing, spontaneous onset 2
• Associated symptoms: Hearing loss/tinnitus/aural fullness (Ménière's disease), headache/photophobia/phonophobia (vestibular migraine), neurological symptoms (central causes) 1, 2
• Vascular risk factors: Age >50, hypertension, atrial fibrillation, diabetes, prior stroke (increases stroke risk to 11-25% even with normal exam) 2

Physical Examination: Essential Bedside Tests

Perform these specific maneuvers—do not simply order imaging: 1, 2

For Triggered Episodic Dizziness (Suspected BPPV):

Dix-Hallpike maneuver (gold standard for posterior canal BPPV): 1, 2, 3

• Diagnostic criteria: 5-20 second latency, torsional upbeating nystagmus toward affected ear, symptoms resolve within 60 seconds 1, 2
• Perform bilaterally to identify the affected side 2
• Supine roll test for horizontal canal BPPV 1

For Acute Persistent Vertigo (Suspected Stroke vs. Vestibular Neuritis):

HINTS examination (Head-Impulse, Nystagmus, Test of Skew): 1, 2, 3

• 100% sensitivity for stroke when performed by trained practitioners (superior to early MRI at 46% sensitivity) 1, 2
• Central features (stroke): Normal head impulse test, direction-changing or vertical nystagmus, present skew deviation 2
• Peripheral features: Abnormal head impulse test, unidirectional horizontal nystagmus, absent skew deviation 2
• Critical caveat: Less reliable when performed by non-experts 1, 2

Observe for spontaneous nystagmus in all patients: 1

• Downbeating, direction-changing, or gaze-evoked nystagmus → central pathology, requires urgent imaging 2

Treatment Based on Diagnosis

BPPV (Most Common Cause):

Canalith repositioning procedures (Epley maneuver) are first-line treatment: 4, 1, 2, 3

• 80% success after 1-3 treatments, 90-98% with repeat maneuvers 1, 2
• No imaging or medication needed for typical cases with positive Dix-Hallpike 1, 2, 3
• Reassess within 1 month to confirm symptom resolution 4

Do NOT routinely prescribe vestibular suppressant medications (antihistamines like meclizine or benzodiazepines) for BPPV: 4

• No evidence these medications are effective as primary treatment or substitute for repositioning maneuvers 4
• May interfere with central compensation and decrease diagnostic sensitivity during Dix-Hallpike 4
• Exception: Short-term use for severe nausea/vomiting in severely symptomatic patients refusing other treatment 4, 5

Observation is an option but patients should be informed about longer symptom duration and potentially higher recurrence rates compared to treatment. 4

Vestibular Neuritis/Labyrinthitis:

Vestibular rehabilitation therapy is the primary intervention for persistent dizziness after initial treatment, significantly improving gait stability compared to medication alone. 2

Ménière's Disease:

• Salt restriction and diuretics 6, 7
• Intratympanic dexamethasone or gentamicin for refractory cases 7
• Obtain audiogram to document low-to-mid frequency sensorineural hearing loss 2

Vestibular Migraine:

Migraine prophylaxis and lifestyle modifications are essential treatment. 2, 8

Medication-Induced Dizziness:

Review and adjust medications (antihypertensives, sedatives, anticonvulsants, psychotropic drugs)—this is a leading reversible cause of chronic dizziness. 2

Imaging Decisions: When NOT to Image

Do NOT order imaging for: 1, 2, 3

• Brief episodic vertigo with typical BPPV features and positive Dix-Hallpike test 1, 2
• Acute persistent vertigo with normal neurologic exam and HINTS consistent with peripheral vertigo (by trained examiner) 1, 2
• Nonspecific dizziness without vertigo, ataxia, or neurologic deficits 1

CT head has extremely low diagnostic yield (<1%) for isolated dizziness and misses most posterior circulation infarcts—do not use instead of MRI when stroke is suspected. 1, 2

Imaging Decisions: When Imaging IS Indicated

Order MRI brain without contrast (NOT CT) for: 1, 2, 3

• High vascular risk patients with acute vestibular syndrome, even with normal neurologic exam (11-25% have posterior circulation stroke) 2
• Abnormal neurologic examination or HINTS suggesting central cause 1, 2
• Unilateral or pulsatile tinnitus, asymmetric hearing loss (exclude vestibular schwannoma) 1, 2
• Progressive neurologic symptoms 1, 2

MRI with diffusion-weighted imaging has 4% diagnostic yield versus <1% for CT, with 70% of positive findings being ischemic stroke. 1

Red Flags Requiring Urgent Evaluation

Immediate imaging (MRI) and neurologic consultation for: 1, 2, 3

• Focal neurological deficits 1, 2
• Sudden unilateral hearing loss 2
• Inability to stand or walk 1, 2
• Downbeating or other central nystagmus patterns 1, 2
• New severe headache accompanying dizziness 1, 2
• Failure to respond to appropriate vestibular treatments 1, 2

Critical pitfall: 75-80% of patients with acute vestibular syndrome from posterior circulation infarct have NO focal neurologic deficits—normal exam does not exclude stroke. 2

Special Considerations for Elderly Patients

Dizziness increases fall risk 12-fold in elderly patients. 2

• BPPV is present in 9% of elderly patients referred for geriatric evaluation, with 75% having fallen within prior 3 months 2
• Document fall history: Number of falls in past year, circumstances, injuries sustained 2
• Counsel about: Recurrence risk (10-18% at one year, up to 36% long-term), fall prevention, home safety assessment 1, 2
• Consider vestibular rehabilitation therapy for persistent symptoms, particularly beneficial for elderly patients with heightened fall risk 2