What are the treatment options for dizziness?

Treatment Options for Dizziness

The treatment of dizziness should be directed at the specific underlying cause, with canalith repositioning procedures being the first-line treatment for benign paroxysmal positional vertigo (BPPV), which is the most common cause of vertigo. 1, 2

Diagnosis-Based Treatment Approach

1. Benign Paroxysmal Positional Vertigo (BPPV)

• First-line treatment: Canalith Repositioning Procedure (Epley maneuver)
  • Success rates of 61-95% after a single treatment 2

  • 10 times more effective than a week of Brandt-Daroff exercises 2

• Alternative treatments:
  • Liberatory Maneuver (Semont maneuver)
  • Gufoni Maneuver (for horizontal canal BPPV)
  • Barbecue Roll Maneuver (Lempert maneuver)
  • Success rates ranging from 71-94% 2
• Self-administered options:
  • Self-administered CRP (64% improvement rate)
  • Brandt-Daroff exercises (23% improvement rate) 2

2. Menière's Disease

• Maintenance therapy options:
  • Diuretics and/or betahistine to reduce symptoms or prevent attacks 1
  • Salt restriction (with appropriate nutritional counseling)
• For active disease not responsive to noninvasive treatment:
  • Intratympanic steroids 1
• NOT recommended:
  • Positive pressure therapy 1
  • Vestibular rehabilitation during acute attacks 1

3. Vestibular Neuritis/Labyrinthitis

• Steroids for vestibular neuritis 2
• Vestibular suppressant medications for short-term symptom relief
• Vestibular rehabilitation for chronic symptoms

4. Presyncope/Orthostatic Hypotension

• Alpha agonists
• Mineralocorticoids
• Lifestyle changes (adequate hydration, salt intake, compression stockings) 2
• Physical counter-pressure maneuvers for patients with sufficient prodromal period 2

Pharmacological Options

Vestibular Suppressants

• Meclizine (antihistamine):
  • Dosage: 25 mg to 100 mg daily, in divided doses 3
  • Useful for acute vertigo symptoms
  • Caution: May cause drowsiness, dry mouth, blurred vision 3
  • Contraindicated in patients with hypersensitivity to meclizine 3
  • Use with care in patients with asthma, glaucoma, or prostate enlargement 3

Important Medication Considerations

• Vestibular suppressants should not be used as routine treatment for BPPV 2
• Short-term use only for severe symptoms to avoid delaying central compensation
• Caution with elderly patients due to increased risk of:
  • Cognitive dysfunction
  • Falls
  • Drug interactions 2

Vestibular Rehabilitation

• Effective for chronic imbalance and dizziness
• Not recommended for acute vertigo attacks in Menière's disease 1
• Can be self-administered or clinician-guided
• Less effective than repositioning maneuvers for BPPV 2

Follow-up and Monitoring

• Reassess patients within 1 month after treatment to confirm symptom resolution 2
• Evaluate for persistent symptoms that may indicate:
  • Treatment failure
  • Coexisting vestibular conditions
  • Serious CNS disorders 1
• For persistent BPPV, repeat canalith repositioning maneuvers can achieve 90-98% success rate 1

Special Considerations

• Elderly patients are at higher risk of falls, depression, and impairments in daily activities with untreated vestibular disorders 2
• Patients with physical limitations may require modified treatment techniques 2
• Patient education about potential recurrence (approximately 36% recurrence rate) is crucial 2

Common Pitfalls to Avoid

1. Overreliance on vestibular suppressant medications, which can delay central compensation
2. Failure to identify and treat the specific underlying cause of dizziness
3. Unnecessary imaging for clear cases of BPPV
4. Not performing follow-up to confirm symptom resolution
5. Overlooking medication side effects as potential causes of dizziness

Remember that the treatment approach should be tailored based on the specific diagnosis, with particle repositioning maneuvers having substantially higher treatment responses (78.6%-93.3%) compared to medication alone (30.8%) for BPPV patients 2.