What are the treatment options for dizziness?

Treatment Options for Dizziness

The most effective treatment for dizziness depends on the underlying cause, with canalith repositioning procedures being significantly more effective (78.6%-93.3% improvement) than medication alone (30.8% improvement) for BPPV, which is one of the most common causes of dizziness. 1

Diagnosis-Based Treatment Approach

• Benign Paroxysmal Positional Vertigo (BPPV):

  • First-line: Canalith Repositioning Procedures (CRP) such as the Epley maneuver or Semont liberatory maneuver 1
  • CRP has 6.5 times greater chance of symptom improvement compared to controls 1
  • Avoid vestibular suppressant medications as primary treatment 1

• Vestibular Neuritis/Labyrinthitis:

  • Short-term use of vestibular suppressants for acute symptoms 2
  • Transition to vestibular rehabilitation as soon as possible 3

• Ménière's Disease:

  • Dietary modifications including salt restriction 2
  • Limited course of vestibular suppressants for acute attacks only 2
  • Consider intratympanic steroid therapy for persistent symptoms 3

• Central Causes of Dizziness:

  • Requires diagnosis-specific treatment 1
  • Neuroimaging should be considered if central vertigo is suspected 3

Vestibular Rehabilitation Therapy

• Recommended as an option for patients with:

  • Additional balance impairments 1
  • Failed initial CRP attempts 1
  • Patients who are not candidates for CRP 1
  • Patients who refuse CRP 1

• Vestibular rehabilitation significantly improves gait stability compared to medication alone 1, 3

• Particularly beneficial for residual dizziness after successful BPPV treatment 1

Medication Options

• Vestibular suppressants (NOT recommended as routine treatment):

  • Meclizine (25-100 mg daily in divided doses) - indicated for vertigo associated with vestibular system diseases 4
  • Should NOT be routinely prescribed for BPPV 1
  • Use only for short-term management of severe symptoms 1, 3

• Potential harms of vestibular suppressants:

  • Drowsiness and cognitive deficits 1, 2
  • Increased risk of falls, especially in elderly patients 1, 2
  • May interfere with central compensation, potentially prolonging symptoms 3
  • Anticholinergic side effects (dry mouth, blurred vision, urinary retention) 2

Special Considerations for Elderly Patients

• Avoid vestibular suppressants when possible due to:

  • Increased fall risk 2
  • Cognitive impairment from anticholinergic burden 2
  • Drug-drug interactions with other medications 2

• Be cautious with polypharmacy as the risk of falls increases with multiple medications 3

Follow-Up Recommendations

• Reassess patients within 1 month after initial treatment to document resolution or persistence of symptoms 1, 3

• If symptoms persist:

  • Evaluate for persistent BPPV or underlying peripheral vestibular or CNS disorders 1
  • Consider additional vestibular rehabilitation if balance and motion tolerance do not improve in a timely manner 1, 3

Common Pitfalls to Avoid

• Relying solely on medications for BPPV treatment when CRP is significantly more effective 1
• Prolonged use of vestibular suppressants, which can delay central compensation 3
• Failure to reassess patients within 1 month after treatment initiation 1
• Overlooking comorbid conditions that may modify management (impaired mobility, CNS disorders, fall risk) 1
• Missing the diagnosis of BPPV in elderly patients with non-specific complaints of dizziness 1