How to treat dizziness based on the underlying cause?

Treatment of Dizziness Based on Underlying Cause

The treatment of dizziness should be specifically targeted to the underlying cause, with canalith repositioning procedures being the first-line treatment for BPPV, corticosteroids for vestibular neuritis, and medication adjustment for orthostatic hypotension. 1

Diagnostic Approach

Before initiating treatment, proper diagnosis is essential:

1. Focus on timing and triggers rather than quality of dizziness symptoms 1, 2

2. Classify dizziness into one of four main categories:

   • Vertigo (sensation of spinning)
   • Presyncope (feeling of impending faint)
   • Disequilibrium (imbalance without spinning)
   • Lightheadedness (vague sensation) 3

3. Key diagnostic tests:

   • Dix-Hallpike maneuver for positional vertigo
   • HINTS examination for acute vestibular syndrome
   • Orthostatic blood pressure measurement
   • Nystagmus evaluation 1

Treatment Based on Specific Causes

1. Benign Paroxysmal Positional Vertigo (BPPV)

• First-line treatment: Canalith Repositioning Procedure (Epley maneuver) 4, 1
  • Success rate of 80% with a single procedure 1
  • Success rate reaches 90-98% with additional repositioning maneuvers 4
• For persistent symptoms: Repeat canalith repositioning maneuvers 4
• For refractory cases: Consider vestibular rehabilitation 1
• Avoid: Routine prescription of vestibular suppressants 1

2. Vestibular Neuritis

• First-line treatment: Early corticosteroid therapy 1
• Adjunct therapy: Vestibular rehabilitation to accelerate central compensation 1
• Caution: Rule out stroke with proper examination (HINTS) 1, 5

3. Menière's Disease

• First-line treatment: Salt restriction and diuretics 6
• For refractory cases: Intratympanic dexamethasone or gentamicin 1

4. Orthostatic Hypotension

• First-line interventions:
  • Medication adjustment (review and modify medications causing hypotension)
  • Hydration
  • Compression stockings
  • Gradual position changes 1
• Pharmacologic options: Alpha agonists, mineralocorticoids 3

5. Labyrinthitis

• Treatment: Similar to vestibular neuritis with attention to any hearing loss 1

6. Vestibular Migraine

• Treatment: Migraine prophylaxis and acute migraine management 1

Pharmacologic Considerations

• Meclizine: Indicated for vertigo associated with diseases affecting the vestibular system

  • Dosage: 25 mg to 100 mg daily in divided doses 7
  • Caution: May cause drowsiness; use care when driving or operating machinery 7
  • Contraindications: Hypersensitivity to meclizine or inactive ingredients 7
  • Potential interactions: CNS depressants and CYP2D6 inhibitors 7

• Vestibular suppressants: Limited use as they may interfere with central compensation 2

Treatment Pitfalls to Avoid

• Misdiagnosis: Failing to perform the Dix-Hallpike maneuver in patients with positional vertigo 1
• Overmedication: Routinely prescribing vestibular suppressants for BPPV 1
• Missing central causes: Not performing HINTS examination when indicated 1
• Unnecessary imaging: Ordering CT or MRI in clear cases of peripheral vertigo 5
• Inadequate follow-up: Not reevaluating patients with persistent symptoms after initial treatment 4

Special Considerations

• Treatment failures: Patients with persistent symptoms after initial treatment require reevaluation for:

  1. Persistent BPPV responsive to additional maneuvers
  2. Coexisting vestibular conditions
  3. Serious CNS disorders that may simulate BPPV 4

• Lateral canal BPPV: May require specific repositioning maneuvers with cure rates of 86-100% with up to 4 treatments 4

• Psychiatric causes: Depression, anxiety, and hyperventilation syndrome may cause lightheadedness and require specific psychiatric treatment 3

By targeting treatment to the specific underlying cause of dizziness, clinicians can effectively manage symptoms and improve patient outcomes.