What are the treatment options for dizziness?

Treatment of Dizziness

The most effective treatment for dizziness depends on the underlying cause, with canalith repositioning procedures being the first-line treatment for benign paroxysmal positional vertigo (BPPV), which is the most common cause of vertigo. 1, 2

Diagnostic Approach to Dizziness

• Dizziness should be classified based on timing and triggers rather than quality of symptoms, as patients often have difficulty describing the quality of their symptoms 3
• The Dix-Hallpike maneuver should be performed to diagnose posterior canal BPPV, which is confirmed when vertigo with torsional, upbeating nystagmus is provoked 4, 1
• The supine roll test should be performed to assess for lateral semicircular canal BPPV 4, 1
• Clinicians should not obtain radiographic imaging or vestibular testing in patients who meet diagnostic criteria for BPPV unless additional signs/symptoms inconsistent with BPPV are present 4

Treatment Based on Specific Causes

For Benign Paroxysmal Positional Vertigo (BPPV)

• Canalith Repositioning Procedure (Epley maneuver) is the treatment of choice for posterior canal BPPV, with success rates of 90-98% when performed correctly 1, 2
• For lateral canal BPPV, the Gufoni maneuver or barbecue roll maneuver should be used, with success rates ranging from 86-100% 1, 2
• Postprocedural restrictions after canalith repositioning are not necessary 4, 1
• Vestibular rehabilitation exercises may be offered as an option, either self-administered or clinician-guided 1, 2
• Clinicians should not routinely treat BPPV with vestibular suppressant medications such as antihistamines or benzodiazepines 4, 2, 5

For Ménière's Disease

• Treatment should focus on reducing severity and frequency of vertigo attacks, relieving associated symptoms, and improving quality of life 2
• Dietary modifications including salt restriction and diuretics are recommended to prevent flare-ups 5
• A limited course of vestibular suppressants may be used for acute attacks only 5

For Vestibular Neuritis

• Steroids are recommended for treatment of vestibular neuritis 6, 3
• Vestibular rehabilitation exercises should be implemented to promote central compensation 2

For Orthostatic Hypotension Causing Presyncope

• Alpha agonists, mineralocorticoids, or lifestyle changes may be used to treat orthostatic hypotension 6
• Medication regimens should be assessed in patients with presyncope, as many medications can cause this type of dizziness 6

Follow-Up and Management of Treatment Failures

• Patients should be reassessed within 1 month after initial treatment to document resolution or persistence of symptoms 4, 1
• If symptoms persist, patients should be evaluated for:
  • Unresolved BPPV (may require repeat repositioning maneuvers) 4, 1
  • Canal conversion (occurs in approximately 6% of cases) 1, 5
  • Underlying peripheral vestibular or central nervous system disorders 4

Important Clinical Considerations

• Symptomatic hypotension in heart failure patients, typically characterized by mild dizziness upon standing, can usually be managed through patient education and counseling without necessitating a reduction in heart failure pharmacotherapy 4
• For elderly patients, vestibular suppressant medications should be used with caution due to increased risk of falls, cognitive deficits, and anticholinergic side effects 5
• For severe cases of BPPV refractory to multiple repositioning maneuvers, surgical options like canal plugging may be considered 1

Common Pitfalls to Avoid

• Relying on medications instead of repositioning maneuvers for BPPV 1, 5
• Failing to reassess patients after initial treatment 1, 5
• Missing canal conversions or multiple canal involvement 1, 5
• Using vestibular suppressant medications for prolonged periods, which can interfere with central vestibular compensation 5