What are the treatment options for dizziness?

Treatment Options for Dizziness

The treatment of dizziness should be directed at the underlying cause, with specific first-line therapies for common conditions including canalith repositioning procedures for BPPV, diuretics and betahistine for Ménière's disease, and vestibular rehabilitation for many peripheral vestibular disorders. 1, 2

Classification and Diagnosis

• Dizziness can be classified into four main categories: vertigo (illusion of motion), presyncope (feeling of impending faint), disequilibrium (imbalance), and lightheadedness (vague sensation) 3, 4
• The timing and triggers of dizziness are more reliable diagnostic indicators than the quality of symptoms reported by patients 4, 5
• Physical examination should include assessment for nystagmus, the Dix-Hallpike maneuver for triggered dizziness, and the HINTS examination when indicated 4, 6

Treatment for Specific Causes

Benign Paroxysmal Positional Vertigo (BPPV)

• Canalith repositioning procedures (e.g., Epley maneuver) are the first-line treatment with success rates of 78.6%-93.3% 1, 7
• Vestibular rehabilitation may be offered as an initial treatment option 1
• Observation with follow-up is another initial management option 1
• Patients should be reassessed within 1 month after treatment to confirm symptom resolution 1

Ménière's Disease

• Diuretics and/or betahistine may be offered as maintenance therapy to reduce symptoms or prevent attacks 1
• Intratympanic steroids may be offered to patients with active Ménière's disease not responsive to noninvasive treatment 1
• Lifestyle modifications including stress reduction, adequate hydration, regular exercise, and sufficient sleep can help manage symptoms 2
• Dietary modifications such as limiting salt/sodium intake and avoiding excessive caffeine, alcohol, and nicotine may reduce or prevent vertigo symptoms 2

Vestibular Neuritis/Labyrinthitis

• Steroids are recommended for vestibular neuritis 3
• Vestibular rehabilitation is helpful for promoting central compensation 2, 4

Medication Management

• Vestibular suppressant medications should be used only for short-term management of severe symptoms rather than as definitive treatment 2, 7
• Meclizine (25 mg to 100 mg daily in divided doses) is the most commonly used antihistamine for peripheral vertigo and should be used primarily as-needed rather than scheduled 2, 8
• Benzodiazepines may be used for short-term management of severe vertigo symptoms and associated anxiety 2
• Prochlorperazine can be used for short-term management of severe nausea or vomiting associated with vertigo, but is not recommended as primary treatment for vertigo itself 2, 7

Important Cautions

• Vestibular suppressant medications can cause significant side effects including drowsiness, cognitive deficits, and interference with driving 2, 8
• Long-term use of vestibular suppressants can interfere with central compensation in peripheral vestibular conditions 2
• Meclizine may cause drowsiness and has potential anticholinergic effects, requiring caution in patients with asthma, glaucoma, or prostate enlargement 8
• Vestibular suppressants are a significant independent risk factor for falls, especially in elderly patients 2, 7

Follow-up and Monitoring

• Patients should be reassessed within 1 month after initial treatment to document resolution or persistence of symptoms 1, 2
• For patients with heart failure experiencing dizziness, evaluation should determine if symptoms are related to heart failure therapy or other etiologies 1
• Transition from medication to vestibular rehabilitation when appropriate to promote long-term recovery 2

Special Considerations

• In patients with heart failure and low blood pressure experiencing dizziness, careful medication management is required, with SGLT2 inhibitors and MRAs being preferred as they typically do not lower blood pressure 1
• Symptomatic hypotension in chronic heart failure with reduced ejection fraction, typically characterized by mild dizziness upon standing, can usually be managed through patient education without reducing heart failure pharmacotherapy 1