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
• They interfere with central compensation and decrease diagnostic sensitivity during Dix-Hallpike maneuvers 4
• Exception: Short-term use for severe nausea/vomiting in severely symptomatic patients refusing other treatments 4
• Meclizine is FDA-approved for vertigo associated with vestibular system diseases, but this does not make it appropriate for BPPV specifically 5

Observation (watchful waiting) is an option but has drawbacks: 4

• Longer symptom duration compared to treatment maneuvers 4
• Potentially higher recurrence rates (10-18% at one year, up to 36% long-term) 1

Counsel patients about: 1, 2

• Fall risk: Dizziness increases fall risk 12-fold in elderly; BPPV present in 9% of elderly patients, with 75% having fallen in prior 3 months 2
• Recurrence risk and need to return promptly for repeat repositioning 1, 2

Vestibular Neuritis/Labyrinthitis:

Vestibular rehabilitation therapy is the primary intervention for persistent dizziness after initial treatment: 2

• Significantly improves gait stability compared to medication alone 2
• Particularly beneficial for elderly patients or those with heightened fall risk 2
• Includes habituation exercises, gaze stabilization, balance retraining, fall prevention 2

Ménière's Disease:

Salt restriction and diuretics are first-line management 2, 6

• Obtain audiogram to document low-to-mid frequency sensorineural hearing loss 2
• MRI head and internal auditory canal with contrast to exclude vestibular schwannoma (for unilateral tinnitus or hearing loss) 1, 2

Vestibular Migraine:

Migraine prophylaxis and lifestyle modifications: 1, 2

• Extremely common (14% of all vertigo) but under-recognized, especially in young patients 2
• Diagnostic criteria: Episodic vestibular symptoms + migraine history + at least two migraine symptoms during two vertiginous episodes 2

Chronic Dizziness:

Medication review is essential (leading reversible cause): 2

• Review antihypertensives, sedatives, anticonvulsants, psychotropic drugs 2
• Screen for psychiatric symptoms (anxiety, panic disorder, depression) 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, 3
• 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 2

CT head has extremely low yield (<1%) for isolated dizziness and misses most posterior circulation infarcts—avoid routine use 1, 2

Imaging Decisions: When Imaging IS Indicated

MRI brain without contrast is indicated for: 1, 2, 3

• Abnormal neurologic examination 1, 2
• HINTS examination suggesting central cause (by trained examiner) 1, 2
• High vascular risk patients with acute vestibular syndrome, even with normal neurologic exam (11-25% have posterior circulation stroke) 2
• Red flag features: 1, 2
  • Focal neurological deficits
  • Sudden unilateral hearing loss
  • Inability to stand or walk
  • Downbeating or central nystagmus patterns
  • New severe headache accompanying dizziness
  • Progressive neurologic symptoms
  • Failure to respond to appropriate vestibular treatments

MRI with diffusion-weighted imaging is far superior to CT (4% diagnostic yield vs <1% for CT) for detecting posterior circulation infarcts 1, 2

Critical Pitfalls to Avoid

• Do not rely on patient descriptions of "spinning" vs "lightheadedness"—focus on timing and triggers instead 1, 2
• Do not assume normal neurologic exam excludes stroke—75-80% of posterior circulation infarcts have no focal deficits 2
• Do not order routine imaging for isolated dizziness—perform appropriate bedside tests first 1, 2
• Do not use CT instead of MRI when stroke is suspected—CT misses most posterior circulation infarcts 2
• Do not prescribe vestibular suppressants for BPPV—they are ineffective and interfere with compensation 4
• Do not overlook vestibular migraine—it accounts for 14% of vertigo cases but is frequently missed 2
• Do not forget medication review in chronic dizziness—it is the leading reversible cause 2