Treatment of Dizziness
The treatment of dizziness must be tailored to the specific underlying cause, with canalith repositioning procedures being the first-line treatment for BPPV, the most common cause of vertigo, rather than medications which should not be routinely prescribed. 1, 2
Diagnosis and Classification of Dizziness
- Dizziness should be classified into one of four categories to guide treatment: vertigo (false sensation of movement), presyncope (feeling of impending faint), disequilibrium (loss of balance), or lightheadedness (vague sensation) 3, 4
- For vertigo, the most common causes are benign paroxysmal positional vertigo (BPPV), Menière's disease, vestibular neuritis, and labyrinthitis 3
- The Dix-Hallpike maneuver should be performed to diagnose posterior canal BPPV, while the supine roll test should be used to diagnose lateral canal BPPV 1
Treatment of BPPV (Most Common Cause of Vertigo)
- Canalith Repositioning Procedure (Epley maneuver) is the treatment of choice for posterior canal BPPV with success rates of 90-98% when performed correctly 2, 5
- For lateral canal BPPV, the Gufoni maneuver or barbecue roll maneuver should be used, with success rates ranging from 86-100% 2
- Vestibular suppressant medications (antihistamines, benzodiazepines) should NOT be routinely prescribed for BPPV treatment as they do not address the underlying cause 1, 5
- Postprocedural restrictions after repositioning maneuvers are unnecessary 2
Treatment of Other Vestibular Causes of Dizziness
- For Ménière's disease, treatment includes salt restriction, diuretics, and short-term vestibular suppressants during acute attacks 6, 4
- For vestibular neuritis, treatment includes short-term vestibular suppressants and vestibular rehabilitation exercises 4
- Vestibular rehabilitation therapy should be considered for patients with persistent dizziness from vestibular causes 5
Treatment of Non-Vestibular Causes of Dizziness
- For presyncope due to orthostatic hypotension, treatment may include alpha agonists, mineralocorticoids, or lifestyle changes 3
- For dizziness associated with heart failure and low blood pressure, careful medication management is required, with SGLT2 inhibitors and MRAs being preferred as they typically do not lower blood pressure significantly 1
- For dizziness related to psychiatric disorders, treatment of the underlying condition is recommended 3, 7
Medication Considerations
- Meclizine (25-100mg daily in divided doses) may be used short-term for severe nausea/vomiting associated with vertigo, but not as primary treatment 6
- Vestibular suppressants should be used cautiously, especially in elderly patients, due to side effects including drowsiness, cognitive deficits, and increased fall risk 6
- Review patient medications as many can cause dizziness, particularly in elderly patients 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 1
- For persistent symptoms, evaluate for unresolved BPPV, canal conversion (occurs in ~6% of cases), or underlying peripheral vestibular or central nervous system disorders 1, 2
- For refractory cases of BPPV not responding to multiple repositioning maneuvers, surgical options like canal plugging may be considered 2