What are the treatment options for dizziness?

Treatment Options for Dizziness

The first-line treatment for dizziness should be based on the underlying cause, with canalith repositioning procedures recommended for BPPV, the most common cause of vertigo, rather than medication. 1

Diagnosis-Based Treatment Approach

• Determine the specific type of dizziness to guide treatment, as different types require different interventions 2
• For BPPV (characterized by brief episodes of vertigo triggered by head position changes), canalith repositioning procedures (CRPs) like the Epley maneuver are the first-line treatment with 78.6%-93.3% improvement rates 2
• For Ménière's disease, a limited course of vestibular suppressants is recommended for acute attacks, with dietary modifications including salt restriction and diuretics for prevention 1, 3
• For vestibular neuritis, short-term vestibular suppressants and vestibular rehabilitation are indicated 4

Non-Pharmacological Interventions

• Canalith repositioning procedures (Epley maneuver) should be the primary treatment for BPPV rather than medication or observation 2, 3
• Vestibular rehabilitation therapy is recommended as an adjunctive treatment for patients with BPPV who have additional impairments, fail initial CRP attempts, are not candidates for CRP, or refuse CRP 2
• Vestibular rehabilitation is particularly beneficial for elderly patients with preexisting balance deficits, CNS disorders, or fall risk 2
• Lifestyle modifications including limiting salt intake, avoiding excessive caffeine, alcohol, and nicotine, maintaining adequate hydration, regular exercise, and stress management can help manage persistent dizziness 1, 5

Pharmacological Options

• Vestibular suppressant medications such as antihistamines (meclizine) and benzodiazepines should NOT be routinely used for BPPV treatment 2
• Meclizine (25-100 mg daily in divided doses) may be considered only for short-term management of severe symptoms rather than as definitive treatment 1, 6
• Vestibular suppressants can cause significant adverse effects including drowsiness, cognitive deficits, and increased fall risk, especially in elderly patients 2, 1
• Betahistine may be effective in reducing symptoms in specific patient subgroups when used concurrently with canal repositioning maneuvers 1, 5

Special Considerations for Elderly Patients

• Vestibular suppressant medications significantly increase fall risk in elderly patients due to drowsiness and cognitive effects 1, 7
• Meclizine has anticholinergic side effects including dry mouth, blurred vision, and urinary retention, which are particularly problematic in elderly patients 1, 6
• Polypharmacy concerns are significant in elderly patients, as they may already be taking multiple medications with potential interactions 5, 7
• Elderly patients with BPPV often have residual dizziness and abnormal postural control even after successful CRP, requiring additional vestibular rehabilitation 2

Follow-Up Recommendations

• Reassess patients within 1 month after initial treatment to document resolution or persistence of symptoms 2, 1
• If symptoms persist after initial treatment, evaluate for persistent BPPV or underlying peripheral vestibular or CNS disorders 2, 5
• For patients with persistent symptoms despite appropriate treatment, consider referral to a specialist 1, 8
• Discontinue vestibular suppressants as soon as possible to avoid interfering with central compensation 2, 1

Treatment Algorithm

1. Identify the type of dizziness (vertigo, presyncope, disequilibrium, or lightheadedness) 3, 4
2. For BPPV: Perform canalith repositioning procedure (Epley maneuver) 2
3. For Ménière's disease: Salt restriction, diuretics, and short-term vestibular suppressants during acute attacks 1, 4
4. For vestibular neuritis: Short-term vestibular suppressants and vestibular rehabilitation 4
5. For presyncope: Assess and modify medications, treat orthostatic hypotension 3, 4
6. For persistent symptoms: Add vestibular rehabilitation therapy 2, 5
7. Reassess within 1 month to document resolution or persistence of symptoms 2, 1

Cautions and Pitfalls

• Avoid long-term use of vestibular suppressants as they can interfere with central compensation and prolong symptoms 2, 1
• Be particularly cautious with vestibular suppressants in elderly patients due to increased risk of falls, cognitive dysfunction, and drug interactions 1, 7
• Do not rely on medications as primary treatment for BPPV as they do not address the underlying cause 2
• Recognize that BPPV can sometimes be in multiple canals or bilateral, requiring multiple treatments 2, 1