What is the best approach to treating dizziness in a patient with no concerning findings on imaging, labs, or physical exam?

Treatment of Dizziness with Normal Imaging, Labs, and Physical Exam

For patients with dizziness who have normal imaging, labs, and physical examination findings, the most appropriate treatment approach is to diagnose and treat for Benign Paroxysmal Positional Vertigo (BPPV) using canalith repositioning procedures rather than medication. 1

Diagnostic Approach

1. Determine the type of dizziness:

   • Focus on timing and triggers rather than symptom quality
   • Perform the Dix-Hallpike maneuver to diagnose posterior canal BPPV
   • Perform the supine roll test if Dix-Hallpike is negative but BPPV is still suspected 1

2. Rule out BPPV first:

   • BPPV is diagnosed when vertigo with torsional, upbeating nystagmus is provoked by the Dix-Hallpike maneuver
   • This is performed by bringing the patient from upright to supine with head turned 45° to one side and neck extended 20° 1

Treatment Algorithm

First-line Treatment: Canalith Repositioning Procedures (CRPs)

1. For posterior canal BPPV (most common):

   • Epley maneuver
   • Semont maneuver
   • No postprocedural restrictions are necessary 1

2. For lateral (horizontal) canal BPPV:

   • Lempert roll (BBQ roll)
   • Gufoni maneuver

Alternative Approaches

1. Observation with follow-up:

   • May be offered as initial management
   • BPPV can resolve spontaneously in approximately 20% of patients by 1 month and up to 50% by 3 months 1

2. Vestibular rehabilitation:

   • May be offered either self-administered or with a clinician
   • Particularly useful for patients with residual symptoms after CRP or with multiple causes of dizziness 1

What NOT to Do

1. Avoid vestibular suppressant medications:

   • Do not routinely treat BPPV with antihistamines (like meclizine) or benzodiazepines 1
   • These medications can delay central compensation and prolong symptoms

2. Avoid unnecessary testing:

   • Do not order additional radiographic imaging if BPPV is diagnosed
   • Do not order vestibular testing if diagnostic criteria for BPPV are met 1

Follow-up Care

1. Reassess within one month after initial treatment to document resolution or persistence of symptoms 1

2. For persistent symptoms:

   • Evaluate for unresolved BPPV
   • Consider underlying peripheral vestibular or central nervous system disorders
   • Refer to specialists if symptoms persist 1, 2

3. Patient education:

   • Inform about potential for recurrence (15% per year, up to 50% at 5 years)
   • Discuss impact on safety and fall risk
   • Emphasize importance of follow-up 2

Special Considerations

• If symptoms persist despite appropriate treatment, consider referral to neurology, ENT, or other specialists
• For elderly patients, provide fall prevention counseling
• Consider that multiple concurrent vestibular disorders may be present in some patients 1

Pitfalls to Avoid

• Overreliance on symptom quality rather than timing and triggers
• Treating with medications before attempting repositioning maneuvers
• Failing to perform appropriate diagnostic maneuvers (Dix-Hallpike, supine roll test)
• Missing central causes of vertigo that may require urgent treatment 3, 4

By following this algorithm, clinicians can effectively manage most cases of dizziness with normal imaging, labs, and physical examination findings, with canalith repositioning procedures being the cornerstone of treatment for BPPV.