Treatment Options for Dizziness
The primary treatment for dizziness depends on the underlying cause, with canalith repositioning procedures (Epley maneuver) being the first-line treatment for BPPV, vestibular suppressants like meclizine for short-term symptomatic relief, and specific treatments for conditions like Ménière's disease and vestibular neuritis. 1
Diagnostic Classification to Guide Treatment
Before selecting treatment, it's essential to classify the type of dizziness:
- Vertigo - sensation of spinning or movement
- Presyncope - feeling of impending faint
- Disequilibrium - unsteadiness when walking
- Lightheadedness - vague sensation of being disconnected
Treatment Options by Specific Conditions
Benign Paroxysmal Positional Vertigo (BPPV)
- First-line treatment: Canalith repositioning procedure (Epley maneuver) with success rates of 61-95% after a single treatment 1
- Alternative maneuvers for different canal involvement:
- Semont maneuver (Liberatory Maneuver)
- Gufoni Maneuver
- Barbecue Roll Maneuver (Lempert maneuver)
- Follow-up: Reassess within 1 month to document resolution or persistence 1
Ménière's Disease
- Medical management:
- Diuretics and/or betahistine to reduce symptoms or prevent attacks
- Lifestyle modifications including sodium restriction, avoiding caffeine, alcohol, and nicotine
- Vestibular suppressants during acute attacks only 1
Vestibular Neuritis/Labyrinthitis
- Acute treatment: Steroids 1
- Symptomatic relief: Short-term vestibular suppressants
Pharmacological Options
Vestibular Suppressants:
Meclizine: 25 mg to 100 mg daily in divided doses 2
- Warning: May cause drowsiness; use caution when driving or operating machinery
- Contraindications: Hypersensitivity to meclizine
- Side effects: Drowsiness, dry mouth, headache, fatigue, vomiting, rarely blurred vision 2
- Important: Limit to short-term use (<1 week) to avoid interference with vestibular compensation 1
Diazepam: Equally effective as meclizine for acute peripheral vertigo 1
- Use with caution due to potential for dependence
Important Clinical Considerations
When to Limit Vestibular Suppressants
- The American Academy of Otolaryngology-Head and Neck Surgery recommends against routine prescription of vestibular suppressant medications 1
- Use should be limited to:
- Severe autonomic symptoms
- Patients who refuse canalith repositioning procedure
- Severe symptoms after repositioning procedure
- Short-term use only (<1 week) 1
Red Flags Requiring Immediate Imaging
- Abnormal HINTS examination suggesting central cause
- Neurological deficits
- First episode of severe vertigo in elderly or those with vascular risk factors
- Atypical presentation or treatment failure 1
Vestibular Rehabilitation
- Not recommended during acute vertigo attacks
- Beneficial for chronic imbalance after acute phase resolution
- Less effective than repositioning maneuvers for BPPV but useful for residual symptoms 1
Special Populations
Elderly Patients
- Higher risk of falls, depression, and impairments in daily activities
- May require modified techniques or specialized examination tables
- BPPV prevalence is 7 times greater in patients over 60 years 1
- Consider medication interactions and side effects carefully
Patient Education
- Inform about safety concerns related to dizziness
- Discuss potential for disease recurrence (approximately 36% for BPPV)
- Emphasize importance of follow-up
- Advise about lifestyle modifications 1
Drug Interactions
- Avoid coadministration of meclizine with other CNS depressants, including alcohol, as this may increase CNS depression 2
- Be aware of potential interactions with CYP2D6 inhibitors when prescribing meclizine 2
Remember that the goal of treatment is to address the underlying cause when possible, provide symptomatic relief when necessary, and restore function while minimizing medication side effects.