Management of Dizziness

Introduction to Dizziness Evaluation

• The American Academy of Otolaryngology-Head and Neck Surgery recommends evaluating dizziness as a primary vestibular or neurologic problem, not a cardiovascular issue, in patients without hypotension or clinically significant bradycardia 1, 2

Blood Pressure and Heart Rate Assessment

• A blood pressure of 143/71 mmHg is considered elevated systolic pressure and does not explain dizziness from a cardiovascular standpoint, according to the European Society of Cardiology 3
• A heart rate of 55 bpm is not pathologically bradycardic unless accompanied by symptoms of hypoperfusion, heart block, or hemodynamic compromise, as stated by the American College of Cardiology 4, 5

Differential Diagnosis

• The American Academy of Otolaryngology-Head and Neck Surgery suggests focusing on timing and triggers rather than the quality of dizziness to narrow the differential diagnosis 1, 2
• Benign paroxysmal positional vertigo (BPPV) is most likely if episodes are episodic and triggered by head movement, lasting <1 minute and provoked by position changes, according to the American Academy of Otolaryngology-Head and Neck Surgery 6, 1

Diagnostic Approach

• The American Academy of Otolaryngology-Head and Neck Surgery recommends against routinely ordering imaging or vestibular testing unless there are atypical features or red flags 6
• No radiographic imaging is needed if diagnostic criteria for BPPV are met without additional concerning signs, as stated by the American Academy of Otolaryngology-Head and Neck Surgery 6

Treatment

• The American Academy of Otolaryngology-Head and Neck Surgery recommends performing the canalith repositioning procedure (Epley maneuver) immediately for BPPV 6
• Vestibular suppressants should not be prescribed for BPPV, as they delay compensation and are ineffective, according to the American Academy of Otolaryngology-Head and Neck Surgery 6

Medication-Related Causes

• If on beta-blockers and symptomatic bradycardia with dizziness, the American Heart Association recommends reducing the beta-blocker dose rather than discontinuing 7, 5

Follow-Up

• The American Academy of Otolaryngology-Head and Neck Surgery recommends reassessing patients within 1 month to document resolution or persistence of symptoms 6

Common Pitfalls to Avoid

• The American College of Cardiology advises against attributing dizziness to "borderline" bradycardia of 55 bpm unless there is heart block or hemodynamic compromise 4, 5
• The American Academy of Otolaryngology-Head and Neck Surgery warns against assuming normal resting BP excludes orthostatic hypotension – always check orthostatic vitals 2

Management of Dizziness and Nystagmus

Primary Recommendation Against Vestibular Suppressants

• The American Academy of Otolaryngology-Head and Neck Surgery recommends against routinely treating dizziness with vestibular suppressant medications such as antihistamines (including meclizine) and benzodiazepines, as there is no evidence that vestibular suppressants are effective as definitive primary treatment for the most common vestibular disorders 8, 9
• Vestibular suppressants delay compensation and are ineffective for benign paroxysmal positional vertigo (BPPV), with studies comparing diazepam, lorazepam, and placebo showing gradual symptom decline in all groups with no additional relief in drug treatment arms 8

Diagnostic Approach and Treatment

• The Dix-Hallpike maneuver should be performed to diagnose posterior canal BPPV when vertigo with nystagmus is provoked by bringing the patient from upright to supine with head turned 45 degrees to one side 9, 10
• The canalith repositioning procedure (Epley maneuver) is the definitive treatment with proven efficacy for BPPV, and should be performed immediately as first-line treatment 8, 9, 10
• Vestibular rehabilitation may be offered as adjuvant therapy for residual dizziness or balance issues after successful repositioning 8

Treatment Considerations

• Meclizine should not be prescribed as a substitute for repositioning maneuvers in BPPV, as it causes drowsiness and has anticholinergic effects 8