What is the appropriate management for a patient experiencing dizziness?

Management of Dizziness

The appropriate management of dizziness begins with categorizing the presentation by timing and triggers—not the patient's vague description—into one of four vestibular syndromes, followed by targeted physical examination and syndrome-specific treatment, with imaging reserved only for red flag features. 1, 2

Initial Clinical Approach: Timing and Triggers Over Descriptions

Focus on duration and triggers, not subjective descriptions like "spinning" versus "lightheadedness"—these patient descriptions are unreliable and clinically misleading. 1, 2

Categorize into Four Vestibular Syndromes:

• Triggered Episodic (seconds to <1 minute): Head position changes suggest BPPV, the most common cause accounting for 42% of all vertigo cases 1, 2
• Spontaneous Episodic (minutes to hours): Suggests vestibular migraine (14% of cases) or Ménière's disease 1, 2
• Acute Vestibular Syndrome (days to weeks): Constant symptoms suggest vestibular neuritis (41% of peripheral vertigo) or posterior circulation stroke (25% of acute vestibular syndrome, rising to 75% in high-risk patients) 1, 2
• Chronic Vestibular Syndrome (weeks to months): Consider medication side effects (leading reversible cause), anxiety/panic disorder, or posttraumatic vertigo 1, 2

Critical History Elements:

• Duration: Seconds = BPPV; minutes to hours = vestibular migraine or Ménière's; days to weeks = vestibular neuritis or stroke 1, 2
• Associated symptoms: Hearing loss, tinnitus, or aural fullness point to Ménière's disease; headache with photophobia/phonophobia suggests vestibular migraine 1, 2
• Vascular risk factors: Age >50, hypertension, atrial fibrillation, diabetes, or prior stroke dramatically increase stroke risk—11-25% of high-risk patients with acute vestibular syndrome have posterior circulation stroke 1, 2
• Medication review: Antihypertensives, sedatives, anticonvulsants, and psychotropic drugs are leading causes of chronic dizziness 2

Physical Examination: Specific Maneuvers, Not Generic Assessments

For Triggered Episodic Symptoms (Suspected BPPV):

Perform the Dix-Hallpike maneuver bilaterally—this is the gold standard diagnostic test. 1, 3

• Positive findings: 5-20 second latency, torsional upbeating nystagmus toward the affected ear, symptoms resolving within 60 seconds 1, 2
• If positive with typical features: No imaging or vestibular testing needed—proceed directly to treatment 1, 2

For Acute Vestibular Syndrome (Suspected Stroke vs. Vestibular Neuritis):

Perform the HINTS examination (Head-Impulse, Nystagmus, Test of Skew)—when performed by trained practitioners, this has 100% sensitivity for stroke versus only 46% for early MRI. 1, 2

• Central features (stroke): Normal head impulse test, direction-changing or vertical nystagmus, present skew deviation 2, 3
• Peripheral features (vestibular neuritis): Abnormal head impulse test, unidirectional horizontal nystagmus, absent skew deviation 2, 3
• Critical caveat: HINTS is unreliable when performed by non-experts—if uncertain, obtain MRI 1, 2

Observe for Spontaneous Nystagmus:

• Downbeating, direction-changing, or gaze-evoked nystagmus: These patterns indicate central pathology and mandate urgent neuroimaging 2, 3

Imaging: When NOT to Image (Most Cases)

Imaging has extremely low yield (<1% for CT, 4% for MRI) in isolated dizziness and is unnecessary in most cases. 1, 2

Do NOT Image:

• Typical BPPV with positive Dix-Hallpike test and no additional concerning features 1, 2
• Acute vestibular syndrome with normal neurologic exam and HINTS showing peripheral features (by trained examiner) 1, 2
• Nonspecific dizziness without vertigo, ataxia, or neurologic deficits 2

DO Image (MRI Brain Without Contrast):

• Red flags: Focal neurologic deficits, sudden unilateral hearing loss, inability to stand/walk, downbeating or central nystagmus patterns, new severe headache 1, 2
• High vascular risk patients with acute vestibular syndrome, even with normal neurologic exam (11-25% have stroke) 1, 2
• HINTS examination suggesting central cause 1, 2
• Unilateral or pulsatile tinnitus (exclude vestibular schwannoma—use MRI with contrast) 1, 2
• Asymmetric hearing loss 1, 2

Critical pitfall: CT head misses most posterior circulation infarcts and has <1% diagnostic yield—never substitute CT for MRI when stroke is suspected. 1, 2

Treatment: Syndrome-Specific Management

BPPV (Most Common Cause):

Perform canalith repositioning procedures (Epley maneuver) immediately—80% success after 1-3 treatments, 90-98% with repeat maneuvers. 1, 2, 3

• No medications needed for typical BPPV 1, 2
• Counsel patients: 10-18% recurrence at one year, up to 36% long-term; fall risk (especially elderly—BPPV present in 9% of elderly patients, three-fourths had fallen within 3 months) 1, 2
• Vestibular rehabilitation therapy for persistent symptoms after repositioning 1, 2

Ménière's Disease:

• Salt restriction and diuretics as first-line management 4, 5
• Obtain audiogram to document low-to-mid frequency sensorineural hearing loss 2
• MRI with contrast to exclude vestibular schwannoma in patients with unilateral symptoms 1, 2
• Quality of life impact: During acute attacks, QOL falls between Alzheimer's disease and end-stage cancer/AIDS—one of the most debilitating non-institutionalized conditions 4

Vestibular Migraine (14% of All Vertigo, Commonly Under-Recognized):

• Migraine prophylaxis and lifestyle modifications 1, 2
• Diagnostic criteria: Episodic vestibular symptoms, migraine by International Headache Society criteria, at least two migraine symptoms during at least two vertiginous episodes 2

Vestibular Neuritis:

• Vestibular suppressants (meclizine is FDA-approved for vertigo associated with vestibular system diseases) 6, 5
• Vestibular rehabilitation therapy significantly improves gait stability compared to medication alone 1, 2
• Steroids may be considered 7

Chronic Vestibular Syndrome:

• Medication review first—this is the leading reversible cause 1, 2
• Screen for psychiatric disorders (anxiety, panic, depression)—common causes of chronic dizziness 2
• Vestibular rehabilitation therapy for persistent symptoms, particularly beneficial for elderly patients or those with heightened fall risk 1, 2

Critical Pitfalls to Avoid

• Don't rely on patient descriptions of "spinning" versus "lightheadedness"—focus on timing and triggers 1, 2
• Don't assume normal neurologic exam excludes stroke—75-80% of posterior circulation infarct patients have no focal deficits 2
• Don't order imaging for typical BPPV—this delays treatment and wastes resources 1, 2
• Don't use CT when stroke is suspected—it misses most posterior circulation infarcts 1, 2
• Don't overlook vestibular migraine—extremely common but under-recognized, especially in young patients 2
• Don't forget medication review—leading reversible cause of chronic dizziness 1, 2
• Don't miss stroke in isolated dizziness—4% of isolated dizziness cases are due to stroke, 70% in posterior circulation 1

Special Populations: Elderly Patients

• Dizziness increases fall risk 12-fold in elderly patients 2
• Document fall history: Number of falls in past year, circumstances, injuries sustained 2
• Age-related vulnerabilities: Reduced thirst, impaired sodium/water preservation, diminished baroreceptor response, reduced heart rate response to orthostatic stress 2
• Home safety assessment and supervision crucial for elderly/frail patients with BPPV 2