How to treat non-specific dizziness from a neurologist's perspective?

Neurological Approach to Non-Specific Dizziness Treatment

The treatment of non-specific dizziness should focus on identifying the underlying cause through timing and triggers rather than symptom quality, with vestibular rehabilitation as the cornerstone therapy for most cases while avoiding long-term vestibular suppressants. 1

Diagnostic Categorization

Before initiating treatment, categorize dizziness based on timing and triggers:

• Acute vestibular syndrome - sudden onset, persistent vertigo
• Spontaneous episodic vestibular syndrome - recurrent episodes without clear triggers
• Triggered episodic vestibular syndrome - episodes provoked by specific actions
• Chronic non-specific dizziness - persistent vague symptoms without clear pattern 1

Essential Diagnostic Tests

1. Orthostatic blood pressure measurements
2. Neurological assessment including cranial nerves
3. Dix-Hallpike maneuver for suspected BPPV
4. HINTS examination (Head-Impulse, Nystagmus, Test of Skew) for acute vestibular syndrome
5. 12-lead ECG to rule out cardiac causes 1

Treatment Algorithm

1. Benign Paroxysmal Positional Vertigo (BPPV)

• First-line: Canalith Repositioning Procedures (CRPs) - 90-98% success rate
  • Epley maneuver for posterior canal BPPV
  • Semont maneuver as alternative
  • Re-evaluate within 1 month to confirm resolution 1

2. Vestibular Neuritis/Labyrinthitis

• Short course of steroids may be beneficial
• Vestibular rehabilitation - essential for recovery
• Avoid long-term vestibular suppressants as they interfere with central compensation 1

3. Vestibular Migraine

• Migraine-specific medications (triptans) for acute episodes
• Prophylactic therapy for frequent episodes
• Trigger avoidance and lifestyle modifications 1

4. Meniere's Disease

• Low-salt diet
• Diuretics
• Intratympanic dexamethasone or gentamicin for refractory cases 1

5. Chronic Non-Specific Dizziness

• Vestibular rehabilitation - primary treatment
• Medication review - identify and taper potentially contributing medications
• Address psychological factors if present
• Fall prevention strategies especially in elderly patients 1

Medication Management

Vestibular Suppressants

• Short-term use only - these medications can interfere with central compensation
• Meclizine (25-100 mg daily in divided doses) can be used briefly for symptom control 1, 2
• Caution: May cause drowsiness and has anticholinergic effects; use carefully in patients with asthma, glaucoma, or prostate enlargement 2
• Avoid routine use for BPPV as recommended by the American Academy of Otolaryngology-Head and Neck Surgery 1

Drug Interactions

• Avoid co-administration with CNS depressants including alcohol as this may increase CNS depression
• Be aware of CYP2D6 inhibitor interactions with meclizine 2

Special Considerations

Elderly Patients

• Implement fall prevention strategies
• Assess home safety
• Consider need for supervision 1

Treatment Failures

• Review diagnosis - consider missed central causes
• Refer to neurology or ENT for persistent undiagnosed dizziness 1
• Consider psychiatric causes - anxiety, depression, and hyperventilation syndrome can cause vague lightheadedness 3

Red Flags Requiring Immediate Attention

• Sudden severe headache with dizziness
• New neurological symptoms
• Inability to walk or stand
• Persistent vomiting with dizziness
• Somnolence or altered mental status 1

Pitfalls to Avoid

1. Overreliance on symptom quality rather than timing and triggers for diagnosis
2. Long-term use of vestibular suppressants which impedes central compensation
3. Failure to perform key diagnostic maneuvers like HINTS or Dix-Hallpike
4. Unnecessary imaging for typical BPPV with positive Dix-Hallpike test
5. Missing central causes of vertigo by not performing appropriate examinations 1, 4