What are the most common treatment methods for chronic dizziness?

Treatment Methods for Chronic Dizziness

The most effective treatment for chronic dizziness depends on identifying the underlying cause, with canalith repositioning procedures for BPPV, vestibular rehabilitation for most vestibular disorders, and targeted therapies for specific conditions like Ménière's disease or vestibular migraine. 1, 2

Diagnosis-Based Treatment Approach

1. Benign Paroxysmal Positional Vertigo (BPPV)

• First-line treatment: Canalith repositioning procedures (Epley or Semont maneuvers) 1, 2
• Success rates of 90-98% when repositioning maneuvers are properly performed 1
• Avoid vestibular suppressant medications as they delay central compensation and provide no definitive treatment 1

2. Ménière's Disease

• First-line treatment: Dietary modifications 1, 2
  • Low-sodium diet (1500-2300 mg daily)
  • Limiting alcohol and caffeine intake
• Medical therapy: Diuretics to reduce endolymphatic hydrops 1, 2
• For persistent symptoms: Consider intratympanic dexamethasone or gentamicin 3

3. Vestibular Neuritis/Labyrinthitis

• Short-term vestibular suppressants for acute symptoms only
• Primary treatment: Vestibular rehabilitation to promote central compensation 4
• Steroids may be beneficial in vestibular neuritis 3

4. Vestibular Migraine

• Acute treatment: NSAIDs (aspirin, ibuprofen, naproxen sodium) as first-line therapy 2
• Preventive treatment: Propranolol (80-240 mg/day) or timolol (20-30 mg/day) 2
• Alternative preventive options: Amitriptyline (30-150 mg/day) or divalproex sodium (500-1500 mg/day) 2

General Treatment Principles

Vestibular Rehabilitation

• Most effective non-pharmacological intervention for many causes of chronic dizziness 1, 5
• Components include:
  • Habituation exercises
  • Gaze stabilization
  • Balance training
  • Sensory substitution
  • Functional and occupational skills retraining 1

Pharmacological Management

• Vestibular suppressants should not be used routinely for chronic dizziness 1, 5
• Meclizine (12.5-25 mg every 4-6 hours) is FDA-approved for vertigo but should be limited to short-term management of severe symptoms 2, 6
• Avoid long-term use of benzodiazepines and antihistamines as they:
  • Interfere with central vestibular compensation
  • Cause sedation and cognitive impairment
  • May lead to dependence 1

Addressing Comorbid Conditions

• Treat underlying factors that may impede vestibular compensation:
  • Visual problems (correct refractive errors, address cataracts)
  • Proprioceptive deficits (manage neuropathies)
  • Psychological disorders (anxiety, depression, fear of falling) 5
  • Cardiovascular issues (manage orthostatic hypotension) 3

Treatment Algorithm

1. Identify the underlying cause through careful history of timing and triggers 7
2. For BPPV: Perform appropriate repositioning maneuver based on canal involvement
3. For other peripheral vestibular disorders: Initiate vestibular rehabilitation
4. For Ménière's disease: Start dietary modifications and consider diuretics
5. For vestibular migraine: Treat acute attacks with NSAIDs and consider prophylaxis
6. For persistent symptoms: Re-evaluate diagnosis and consider:
   • Inadequate compensation due to comorbidities
   • Psychological overlay requiring specific intervention
   • Mixed or multiple vestibular disorders

Common Pitfalls to Avoid

• Overreliance on vestibular suppressants: These medications should be limited to short-term symptomatic relief only 1, 5
• Failure to identify the specific cause: Treatment should target the underlying etiology rather than symptoms alone 7
• Inadequate follow-up: Reassess within one month to evaluate treatment response 1
• Missing central causes: Use HINTS examination when indicated to distinguish between peripheral and central etiologies 7, 4
• Neglecting psychological factors: Anxiety and depression can perpetuate dizziness symptoms and require specific treatment 5, 8

By following this structured approach to chronic dizziness, clinicians can effectively manage most cases and improve patients' quality of life while minimizing unnecessary medication use and potential side effects.