Applied Evidence

Standardizing your approach to dizziness and vertigo

J Fam Pract. 2018 August;67(8):490-492,495-498

From The Journal of Family Practice | 2018;67(8):490-492,495-498.

References

1. Bisdorff A, Von Brevern M, Lempert T, et al. Classification of vestibular symptoms: towards an international classification of vestibular disorders. J Vestib Res. 2009;19:1-13.

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Performing the barbecue roll maneuver. Different PRMs exist to treat less common variants of BPPV, including the “barbecue roll” maneuver for horizontal BPPV (see https://www.youtube.com/watch?v=mwTmM6uF5yA for a demonstration of this maneuver).²⁵The barbecue roll maneuver is initiated with the patient looking ahead and lying back. For a left-sided horizontal canal otolith, the patient first turns to the left decubitus position, then moves clockwise to the right decubitus position, stopping at each position for approximately 20 seconds, all while maintaining a straight head position. The patient then turns clockwise into a prone position, pausing, and finally turning into the left decubitus position again. The maneuver is completed with the patient sitting up.

Medications are used to treat symptoms and/or underlying causes

Adjustments in antihypertensives can be made in cases of orthostatic hypotension.¹⁷ Antiemetics (ondansetron, promethazine, metoclopramide), antihistamines (meclizine, dimenhydrinate, diphenhydramine), and benzodiazepines (lorazepam, diazepam) may be used during acute and brief vertiginous episodes to decrease symptom severity after central causes have been ruled out.^26,27 However, patients with BPPV should avoid these medications as they may blunt central compensation and increase the risk of falls.²⁷ Research has shown betahistine to improve vertigo control only in patients with Meniere’s disease and only when taken regularly and prophylactically.²⁸ Therefore, do not prescribe betahistine for all other causes of dizziness/vertigo.²⁸

Consider physiotherapy

All patients with dizziness/vertigo, and particularly those presenting with primary balance concerns, may benefit from vestibular rehabilitation therapy (VRT). This is an exercise-based program focusing on habituation of dizziness and improvement of postural stability.²⁹ VRT can improve dizziness associated with central and peripheral vestibular lesions, vertigo of uncertain etiology, and psychogenic vertigo.³⁰ Typically, the vestibular physiotherapist will provide home exercises for the patient, reducing the cost and inconvenience of attending multiple sessions.

Surgery and referrals

Referrals for surgery are rare and are typically reserved for refractory causes of vestibular disease, such as Meniere’s disease, BPPV, SSCD syndrome.³¹

Torsional nystagmus is necessary for a positive Dix-Hallpike, which is diagnostic for benign paroxysmal positional vertigo.

Referral to the ED is warranted for symptom control if an acute vertiginous episode is refractory to initial management. Emergent or urgent neurology consultation is indicated for suspected or confirmed central disorders. Urgent cardiology referral is recommended for patients with symptoms of presyncope/syncope, arrhythmia, or persistent orthostatic hypotension after conservative management. Outpatient referral to an otolaryngologist is warranted if the patient has failed a course of balance physiotherapy, has a persistently positive Dix-Hallpike test after a PRM and vestibular/balance physiotherapy, or has asymmetric hearing loss.

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