Management of Persistent Dizziness

Initial Assessment and Diagnosis

The European Society of Cardiology recommends that if a patient's blood pressure is stabilizing but dizziness persists, the dizziness is likely not caused by the blood pressure medications, and other causes should be actively searched for rather than adjusting cardiovascular therapy 1
The American Academy of Otolaryngology-Head and Neck Surgery suggests performing the Dix-Hallpike maneuver and supine roll test to diagnose BPPV, which accounts for 42% of vertigo cases in primary care 2
The assessment for nystagmus patterns, such as direction-changing nystagmus without head position changes, downward nystagmus, or basal nystagmus without provocation, indicates central nervous system pathology requiring urgent evaluation 3

The European Society of Cardiology states that in patients stable on guideline-directed medical therapy (GDMT) who develop low blood pressure with dizziness, the cardiovascular medications are unlikely the cause, and other causes should be looked for first 1
Patient education is critical, as transient mild dizziness upon standing is a common side effect of life-prolonging heart failure drugs and does not require dose reduction 1
The American College of Cardiology recommends assessing congestion status first, and if no signs of congestion are present, cautiously reducing diuretics rather than stopping GDMT medications 1

The American Academy of Otolaryngology-Head and Neck Surgery suggests using timing and triggers to narrow the differential diagnosis, including triggered episodic dizziness, spontaneous episodic dizziness, and chronic persistent dizziness 2
BPPV is the most common cause of triggered episodic dizziness, with a success rate of 90-98% with the Epley maneuver 4
Postural hypotension, perilymph fistula, vestibular migraine, Ménière's disease, and posterior circulation TIA are other potential causes of dizziness 2

The European Society of Cardiology recommends performing the Dix-Hallpike maneuver for posterior canal BPPV, and if positive, performing the Epley maneuver immediately 4
If symptoms persist after 2-3 repositioning attempts, an MRI brain should be considered to exclude central pathology 3
The American College of Cardiology suggests identifying all medications causing dizziness, including antihypertensives, cardiovascular drugs, and anticonvulsants, and avoiding benzodiazepines as they impede vestibular compensation 1, 5, 6

The European Society of Cardiology warns against assuming cardiovascular medications are the cause of dizziness in stable patients, as this leads to inappropriate discontinuation of life-saving therapy 1
The American College of Radiology recommends avoiding CT head for isolated dizziness, as the diagnostic yield is less than 1% and sensitivity is only 20-40% for causative pathology 7
The American Academy of Otolaryngology-Head and Neck Surgery suggests not prescribing vestibular suppressants (meclizine) for BPPV, as they do not address the underlying cause and may impede compensation 4

The American College of Radiology recommends MRI brain (not CT) for atypical or refractory symptoms after 2-3 repositioning attempts, central nystagmus patterns, associated neurological symptoms, and persistent isolated dizziness with high vascular risk factors 3, 5, 7
CT head has a very low yield (less than 1%) and should be avoided for isolated dizziness without other neurological deficits 7