What is the initial treatment for dizziness (vertigo)?

Initial Treatment for Dizziness (Vertigo)

The initial treatment for benign paroxysmal positional vertigo (BPPV) should be a canalith repositioning procedure (CRP), such as the Epley maneuver, rather than medication. 1, 2

Diagnosis and Classification

• BPPV is diagnosed when vertigo with characteristic nystagmus is provoked by the Dix-Hallpike maneuver (for posterior canal BPPV) or the supine roll test (for lateral canal BPPV) 3, 1
• Posterior semicircular canal BPPV is the most common form, followed by lateral canal BPPV 1
• Clinicians should differentiate BPPV from other causes of imbalance, dizziness, and vertigo before initiating treatment 3

First-Line Treatment Options

For Posterior Canal BPPV:

• Canalith Repositioning Procedure (Epley maneuver) is the treatment of choice with success rates of 90-98% when performed correctly 3, 1
• The Epley maneuver involves a specific sequence of head positions:
  • Patient seated upright with head turned 45° toward affected ear 1
  • Rapidly moved to supine position with head hanging 20° below horizontal 1
  • Head turned 90° to unaffected side 1
  • Head and body turned another 90° (face down position) 1
  • Return to sitting position 1

For Lateral Canal BPPV:

• Gufoni maneuver or barbecue roll maneuver should be used, with success rates ranging from 86-100% 3, 1

Important Treatment Considerations

• Vestibular suppressant medications (antihistamines, benzodiazepines) should NOT be routinely used for BPPV treatment 3, 1
• Meclizine is FDA-approved for vertigo associated with vestibular system diseases but should be reserved for managing severe nausea or vomiting, not as primary BPPV treatment 4
• Postprocedural restrictions after repositioning maneuvers are not necessary 1
• Patients should be reassessed within 1 month after initial treatment to confirm symptom resolution 3, 2

Alternative or Adjunctive Treatments

• Vestibular rehabilitation exercises may be offered as an option, either self-administered or clinician-guided 3, 1
• Observation with follow-up may be considered as initial management for some patients with BPPV 3
• Brandt-Daroff exercises are significantly less effective than CRP but may be used in some cases 1

Management of Treatment Failures

• If symptoms persist after initial treatment, patients should be reevaluated for:
  • Persistent BPPV 3
  • Coexisting vestibular conditions 3
  • Central nervous system disorders mimicking BPPV 3
• Canal conversion occurs in approximately 6% of cases (posterior canal BPPV may convert to lateral canal BPPV and vice versa) and requires appropriate repositioning for the newly affected canal 3, 2
• For cases refractory to multiple CRPs, surgical options like canal plugging may be considered, with success rates >96%, though evidence quality is limited 3

Common Pitfalls to Avoid

• Relying on medications instead of repositioning maneuvers 3, 1
• Failing to reassess patients after initial treatment 3
• Missing canal conversions or multiple canal involvement 3
• Ordering unnecessary radiographic imaging or vestibular testing in patients with typical BPPV 3
• Overlooking central causes of vertigo that may mimic BPPV, especially in treatment failures 3