Management of Dizziness
The primary management of dizziness should focus on identifying the specific cause and implementing targeted treatment, with canalith repositioning procedures being the most effective first-line treatment for benign paroxysmal positional vertigo (BPPV), while avoiding routine use of vestibular suppressant medications. 1
Diagnostic Approach
Classification of Dizziness
- Vertigo: sensation of spinning or movement
- Disequilibrium: unsteadiness or imbalance
- Presyncope: feeling of impending faint
- Lightheadedness: vague sensation of disconnection
Key Diagnostic Tests
- Dix-Hallpike maneuver - essential for diagnosing posterior canal BPPV 1
- Supine roll test - for lateral canal BPPV when Dix-Hallpike is negative 1
- HINTS examination - for distinguishing peripheral from central causes of acute vertigo 2
- Orthostatic blood pressure - for presyncope evaluation 2
Management Based on Etiology
1. Benign Paroxysmal Positional Vertigo (BPPV)
- First-line treatment: Canalith Repositioning Procedures (CRP) 1
- Posterior canal BPPV: Epley maneuver
- Lateral canal BPPV: Barbecue roll maneuver
- Follow-up within 1 month to confirm symptom resolution 1
- Vestibular rehabilitation as adjunctive therapy, especially for:
- Patients with residual dizziness after successful CRP
- Elderly patients with balance disorders
- Patients at high risk for falls 1
2. Vestibular Neuritis/Labyrinthitis
- Avoid prolonged use of vestibular suppressants (beyond 2-3 days) 3
- Early mobilization and vestibular rehabilitation to promote central compensation 3
- Short-term corticosteroids may be beneficial in vestibular neuritis 3
3. Ménière's Disease
- Salt restriction and diuretics for long-term management
- Intratympanic dexamethasone or gentamicin for refractory cases 4
4. Medication-Related Dizziness
- Review and modify medication regimens that may cause dizziness 5, 6
- Common culprits: antihypertensives, sedatives, antidepressants
5. Orthostatic Hypotension
- Lifestyle modifications: gradual position changes, adequate hydration
- Pharmacologic options: alpha agonists, mineralocorticoids 4
Important Considerations
Medication Use
- Avoid routine use of vestibular suppressants (antihistamines, benzodiazepines) 1
- These medications may:
- Interfere with central compensation
- Cause drowsiness and cognitive impairment
- Increase fall risk, especially in elderly patients
- Limited indications for vestibular suppressants:
- These medications may:
Fall Prevention
- Counsel patients about increased fall risk with BPPV and vestibular disorders 1
- Home safety assessment for elderly patients or those with balance disorders
- Consider assistive devices for patients with persistent imbalance
Special Considerations for Elderly Patients
- Dizziness is often multifactorial in older adults 5
- Higher risk of medication side effects and drug interactions
- More likely to require vestibular rehabilitation after successful CRP 1
- May need longer follow-up due to slower recovery
Follow-up Recommendations
- Reassess within 1 month after initial treatment 1
- Evaluate for persistent BPPV or development of other vestibular disorders
- Consider additional testing if symptoms persist despite appropriate treatment
- Refer to specialists (neurology, otolaryngology) for refractory cases
Common Pitfalls to Avoid
- Overreliance on vestibular suppressants which delay recovery 1, 3
- Failure to identify BPPV as a cause of chronic dizziness
- Missing central causes of vertigo that may require urgent intervention
- Inadequate patient education about expected course and recurrence risk
- Not addressing psychological aspects (anxiety, fear of falling) that can perpetuate symptoms 5
Remember that BPPV has a recurrence rate of 5-13.5% at 6 months and 10-18% at 1 year, with rates increasing over time to as high as 36%. Patients should be counseled about this recurrence risk and educated about recognizing symptoms for prompt treatment 1.