What are the treatment options for chronic dizziness?

Treatment Options for Chronic Dizziness

The treatment of chronic dizziness requires a diagnosis-based approach targeting the underlying cause, with vestibular rehabilitation being the most effective first-line therapy for most cases of chronic dizziness. 1

Diagnostic Approach to Guide Treatment

Before initiating treatment, it's crucial to identify the underlying cause of chronic dizziness:

• Benign Paroxysmal Positional Vertigo (BPPV): Diagnose using Dix-Hallpike maneuver
• Vestibular Neuritis/Labyrinthitis: History of sudden onset vertigo lasting days
• Menière's Disease: Episodic vertigo with fluctuating hearing loss, tinnitus, and aural fullness
• Vestibular Migraine: Dizziness associated with migraine features
• Central Causes: Evaluate using HINTS examination (Head-Impulse, Nystagmus, Test of Skew)
• Persistent Postural-Perceptual Dizziness (PPPD): Chronic non-vertiginous dizziness worsened by upright posture, movement, and visual stimuli

Treatment Options Based on Diagnosis

1. BPPV

• First-line: Canalith repositioning procedures (CRPs) like the Epley maneuver (80-90% success rate) 1
• Follow-up: Teach patients self-administered maneuvers for recurrences

2. Vestibular Neuritis/Labyrinthitis

• Acute phase: Short-term vestibular suppressants (≤3 days)
• Recovery phase: Vestibular rehabilitation exercises to promote central compensation

3. Menière's Disease

• First-line: Salt restriction and diuretics 2
• Lifestyle modifications: Reduce caffeine, alcohol, and stress
• Symptomatic relief: Short-term vestibular suppressants during acute attacks
• Advanced options: Consider referral to otolaryngology for intratympanic therapies 3

4. Vestibular Migraine

• Prophylaxis: Beta-blockers (propranolol, metoprolol), anticonvulsants (topiramate, valproate), or antidepressants (amitriptyline) 3
• Avoid triggers: Identify and manage migraine triggers
• Acute treatment: Triptans (if no contraindications) and antiemetics

5. Persistent Postural-Perceptual Dizziness (PPPD)

• First-line: Vestibular rehabilitation combined with cognitive-behavioral therapy 4
• Pharmacotherapy: SSRIs or SNRIs may be beneficial

Core Treatment Approaches

1. Vestibular Rehabilitation

• Most effective first-line therapy for most causes of chronic dizziness
• Includes habituation exercises, gaze stabilization, and balance training
• Particularly beneficial for elderly patients 1
• Shown to reduce dizziness handicap in randomized controlled trials 4

2. Pharmacotherapy

• Vestibular suppressants (meclizine, dimenhydrinate):

  • FDA-approved for vertigo associated with vestibular disorders 5
  • Use only short-term (≤3 days) during acute symptoms
  • Avoid long-term use as they may impede central compensation 6

• Antiemetics (metoclopramide, domperidone):

  • Useful for managing associated nausea without interfering with vestibular compensation 1

• Condition-specific medications:

  • Migraine prophylaxis for vestibular migraine
  • Diuretics for Menière's disease
  • SSRIs/SNRIs for PPPD or associated anxiety

3. Psychological Support

• Cognitive-behavioral therapy for anxiety-related dizziness or PPPD
• Address fear of falling, which can perpetuate symptoms
• Particularly important when symptoms persist despite appropriate treatment 4

Treatment Pitfalls to Avoid

• Overuse of vestibular suppressants: Limit to ≤3 days during acute episodes to prevent interference with central compensation 1, 6
• Failure to diagnose underlying cause: Treatment should target specific etiology rather than symptoms alone
• Neglecting comorbidities: Address vision problems, proprioceptive deficits, and psychological factors that may impede recovery 6
• Polypharmacy: Review medications as some can cause or exacerbate dizziness 1

Special Populations

• Elderly patients:

  • Use lower doses of medications due to higher fall risk
  • Vestibular rehabilitation particularly beneficial 1
  • Home safety assessment recommended

• Patients with renal impairment:

  • Careful medication management required
  • Increased risk of adverse effects from certain medications 1

By following this diagnosis-based approach to treatment, most patients with chronic dizziness can experience significant improvement in symptoms and quality of life.