How is dizziness treated?

Treatment of Dizziness

The most effective treatment for dizziness depends on identifying its specific cause, with canalith repositioning procedures (CRPs) being the first-line treatment for benign paroxysmal positional vertigo (BPPV), the most common cause of vertigo, rather than medication. 1

Diagnostic Approach to Dizziness

Dizziness must first be classified into one of four categories to guide treatment:

1. Vertigo: Sensation of spinning or movement
2. Presyncope: Feeling of impending faint
3. Disequilibrium: Unsteadiness when standing/walking
4. Lightheadedness: Vague sensation of disconnection

Key Diagnostic Tests

• Dix-Hallpike maneuver: To diagnose posterior canal BPPV
• Supine roll test: To diagnose horizontal canal BPPV
• HINTS examination: To distinguish peripheral from central causes
• Orthostatic blood pressure measurement: For presyncope

Treatment Algorithm Based on Cause

1. Benign Paroxysmal Positional Vertigo (BPPV)

• First-line treatment: Canalith Repositioning Procedures (CRPs)
  • Posterior canal BPPV: Epley maneuver (success rate ~80% with 1-3 treatments) 1
  • Horizontal canal BPPV: Barbecue roll maneuver
• Important: Do not routinely prescribe vestibular suppressant medications for BPPV 1
• Follow-up: Reassess within 1 month to document resolution or persistence 1

2. Vestibular Neuritis/Labyrinthitis

• Short-term steroids
• Vestibular rehabilitation exercises
• Vestibular suppressants only for acute severe symptoms (3-5 days maximum)

3. Meniere's Disease

• Salt restriction
• Diuretics
• Intratympanic dexamethasone or gentamicin for refractory cases 1

4. Orthostatic Hypotension/Presyncope

• Alpha agonists
• Mineralocorticoids
• Lifestyle modifications (hydration, compression stockings)

5. Psychiatric Causes (Anxiety, Depression)

• Treat underlying psychiatric condition
• Avoid vestibular suppressants

Role of Medications in Dizziness Management

Vestibular suppressant medications should NOT be routinely prescribed for BPPV and should be limited to specific situations:

• Short-term management of severe nausea/vomiting
• Patients refusing other treatment options
• Prophylaxis before CRP in patients with severe symptoms 1

When needed, meclizine can be used at 25-100 mg daily in divided doses, but may cause drowsiness and has anticholinergic effects 2.

Vestibular Rehabilitation

Vestibular rehabilitation (VR) has an important role:

• Not as a substitute for CRP in BPPV
• As adjunctive therapy for:
  • Patients with additional balance impairments
  • Those who fail initial CRP attempts
  • Patients with persistent dizziness after successful CRP 1

Common Pitfalls to Avoid

1. Overreliance on imaging: Radiographic imaging is not recommended for diagnosed BPPV unless diagnosis is uncertain or there are atypical neurological symptoms 1

2. Prolonged use of vestibular suppressants: These medications can:

   • Delay central compensation
   • Increase fall risk, especially in elderly
   • Cause cognitive deficits and drowsiness 1

3. Missing bilateral or multi-canal BPPV: These cases often require more treatments and specialized care 3

4. Inadequate follow-up: Patients should be reassessed within one month to confirm resolution or need for additional treatment 1

Special Considerations for Elderly Patients

Elderly patients with BPPV require special attention due to:

• Higher risk of falls
• More likely to have comorbid balance disorders
• May need home supervision or safety assessment 1
• May benefit more from vestibular rehabilitation as adjunctive therapy 1

Remember that BPPV can recur, and patients should be educated about this possibility and the availability of effective treatments if symptoms return.