Management of Orthostatic Dizziness

Initial Assessment and Diagnosis

The American College of Cardiology recommends confirming orthostatic hypotension by measuring blood pressure after 5 minutes of lying/sitting, then at 1 and 3 minutes after standing, with a drop of ≥20 mmHg systolic or ≥10 mmHg diastolic confirming the diagnosis 1
Identify and discontinue medications that exacerbate orthostatic symptoms, including psychotropic drugs, diuretics, α-adrenoreceptor antagonists, centrally-acting antihypertensives, and vasodilators, as recommended by the European Society of Cardiology 2, 1, 3

The American Heart Association suggests increasing fluid intake to 2-3 liters daily, unless contraindicated by heart failure, to help manage orthostatic dizziness 1
Increase salt consumption to 6-9 grams daily, if not contraindicated, as recommended by the American College of Cardiology 2, 1
Teach gradual staged movements with postural changes, avoiding rapid standing, as suggested by the European Society of Cardiology 2, 1

Midodrine is the first-line pharmacological agent with the strongest evidence base, supported by three randomized placebo-controlled trials and FDA approval, according to the American College of Cardiology 1
The European Society of Cardiology recommends dosing midodrine at 2.5-5 mg three times daily, with the first dose taken before arising, and the last dose taken at least 3-4 hours before bedtime to prevent supine hypertension during sleep 2, 1
Fludrocortisone is another first-choice agent that acts through sodium retention and vessel wall effects, with dosing starting at 0.05-0.1 mg daily, as recommended by the American Heart Association 2, 1

Cardioselective β-blockers without intrinsic sympathomimetic activity, such as metoprolol, nebivolol, and bisoprolol, can be used to treat resting tachycardia associated with autonomic neuropathy in diabetic patients, according to the European Association for the Study of Diabetes 2, 4
Consider α-lipoic acid for potential benefits on autonomic function in diabetic patients, as suggested by the American Diabetes Association 4, 1

Monitor for supine hypertension, which is the most important limiting factor and can cause end-organ damage, as recommended by the American College of Cardiology 1
Measure blood pressure in supine, sitting, and standing positions at follow-up visits, according to the European Society of Cardiology 1
Balance the goal of increasing standing blood pressure against the risk of supine hypertension, as suggested by the American Heart Association 2, 1