What are the treatments for dizziness (vertigo)?

Treatment of Dizziness (Vertigo)

The primary treatment for benign paroxysmal positional vertigo (BPPV), the most common cause of vertigo, is canalith repositioning procedures (CRP) with success rates of 80-90% after 1-2 treatments, not medication. 1, 2

Diagnosis and Classification

Before treatment, proper diagnosis is essential:

• Peripheral vs. Central Vertigo: Distinguish using HINTS examination (Head-Impulse, Nystagmus, Test of Skew) 2
• BPPV Diagnosis: Confirmed with Dix-Hallpike test (gold standard) or supine roll test 1, 2
• Common Causes: BPPV (38.8%), vestibular migraine, vestibular neuritis, Menière's disease, and vascular causes 2, 3

Treatment Algorithm

1. BPPV (Most Common Cause)

• First-line: Canalith Repositioning Procedures (CRP) such as Epley maneuver 1

  • Success rate: 80-90% after 1-2 treatments
  • Can be performed during diagnostic testing
  • May cause brief distress, vertigo, nausea during procedure

• For patients unable to undergo CRP (cervical stenosis, severe arthritis, obesity, etc.):

  • Self-repositioning exercises under supervision 1
  • Vestibular rehabilitation therapy 1, 2

2. Vestibular Suppressant Medications

• Not recommended for routine BPPV treatment 1
• Short-term use only for severe symptoms or when CRP is delayed 1, 2
• Options include:
  • Meclizine (FDA-approved for vertigo) 4
  • Antihistamines
  • Benzodiazepines (lorazepam)
  • Dopamine receptor antagonists (prochlorperazine, metoclopramide)

3. Vestibular Rehabilitation

• Indicated for:

  • Patients who fail initial CRP
  • Those with additional balance impairments
  • Elderly patients with fall risk
  • Patients with persistent symptoms after successful CRP 1

• Components:

  • Habituation exercises
  • Balance retraining
  • Gait training
  • Fall prevention strategies 2

4. Specific Treatments for Other Vertigo Causes

• Vestibular Neuritis/Labyrinthitis:

  • Short course of oral corticosteroids (7-14 days with tapering)
  • Antibiotics if bacterial cause suspected 2

• Menière's Disease:

  • Diuretics (reduce endolymph volume)
  • Low-salt diet
  • Transtympanic gentamicin for refractory cases with non-usable hearing 2

• Vestibular Migraine:

  • Beta-blockers, anticonvulsants, or antidepressants for prophylaxis 2

• Central Vertigo (stroke, MS):

  • Urgent neuroimaging and neurological consultation
  • Treatment of underlying cause 5, 6

Follow-up and Monitoring

• Reassessment within 1 month after initial treatment to document resolution or persistence 1
• Monitor for recurrence: BPPV has 10-18% recurrence rate at 1 year, up to 36% long-term 2

Special Considerations

Elderly Patients

• Higher fall risk requires more aggressive management
• Home safety assessment recommended
• Consider vestibular rehabilitation even after successful CRP 1, 2

Persistent Symptoms

• If symptoms persist beyond 1 month despite appropriate treatment:
  • Reassess diagnosis
  • Consider additional vestibular testing
  • Evaluate for comorbid conditions (anxiety, depression) 1

Common Pitfalls

1. Overuse of vestibular suppressant medications which can delay vestibular compensation 2
2. Failure to diagnose central causes of vertigo (stroke, MS) which require different management 5, 6
3. Not addressing fall risk in elderly patients with vertigo 1, 2
4. Missing BPPV diagnosis due to improper testing technique 1

Remember that while observation alone may lead to spontaneous resolution in 15-85% of BPPV cases within a month, active treatment with CRP provides faster symptom relief and reduces fall risk, especially in elderly patients 1.