What are the treatment options for chronic dizziness?

Treatment of Chronic Dizziness

Vestibular rehabilitation therapy is the primary treatment for chronic dizziness, particularly when symptoms persist despite initial interventions, as it promotes central compensation and provides superior long-term outcomes compared to medication alone. 1

Initial Diagnostic Approach

Before initiating treatment, establish the original cause of dizziness through targeted history:

• Determine if the chronic symptoms began as BPPV, vestibular neuritis, vestibular migraine, Ménière's disease, or brainstem stroke 2
• Assess whether the original acute symptoms are still present or if you're dealing purely with chronic residual dizziness 2
• Identify factors impeding central vestibular compensation: visual problems (cataracts, squints), proprioceptive deficits (diabetic or alcoholic neuropathy), neurological/orthopedic comorbidities, reduced mobility, fear of falling, or psychiatric disorders 2
• Rule out neurological gait disorders through comprehensive neurological examination 2

First-Line Treatment: Vestibular Rehabilitation

Vestibular rehabilitation therapy should be offered as the primary intervention for persistent dizziness that has failed multiple medication trials 1. This recommendation is based on evidence showing:

• Significantly improved overall gait stability compared to medication alone, particularly in patients with residual dizziness after BPPV treatment 1
• Especially indicated when balance and motion tolerance do not improve in a timely manner despite other interventions 3, 1
• Critical for patients who develop chronic subjective dizziness or persistent perceptual postural dizziness following acute vestibular events 3

The American Academy of Otolaryngology-Head and Neck Surgery emphasizes that increased balance performance is achieved only when movement/habituation-based vestibular rehabilitation is administered, not with repositioning procedures alone 3.

Medication Management: Use Sparingly

Vestibular Suppressants (Antihistamines/Benzodiazepines)

Vestibular suppressant medications should NOT be used routinely for chronic dizziness and should only be reserved for short-term management of severe acute symptoms 3, 1. The evidence strongly supports this recommendation:

• No evidence suggests vestibular suppressants are effective as definitive primary treatment for chronic vestibular disorders 3
• Studies comparing diazepam, lorazepam, and placebo showed no additional symptom relief in medication groups 3
• Canalith repositioning maneuvers demonstrate 78.6%-93.3% improvement versus only 30.8% with medication alone 3, 1
• Patients who underwent repositioning maneuvers alone recovered faster than those who received concurrent vestibular suppressants 3

Critical Warnings About Vestibular Suppressants

Long-term use of vestibular suppressants interferes with central compensation in peripheral vestibular conditions, potentially prolonging symptoms 1. Additional harms include:

• Drowsiness, cognitive deficits, and interference with driving or operating machinery 1, 4
• Significantly increased fall risk, especially in elderly patients 1
• Benzodiazepines are a significant independent risk factor for falls and should be discontinued 1
• Risk increases with polypharmacy 1

Meclizine is FDA-approved for vertigo associated with vestibular system diseases at doses of 25-100 mg daily 4, but should be prescribed with caution in patients with asthma, glaucoma, or prostate enlargement due to anticholinergic effects 4.

Betahistine: Limited Role

Betahistine (16-48 mg three times daily) may be effective only in specific patient subgroups: those over 50 years old with hypertension and symptom onset less than 1 month 1. However:

• Recent high-quality trials show no significant difference between betahistine and placebo for vertigo control 1
• Evidence for efficacy is mixed and generally weak 1

Treatment of Specific Underlying Conditions

If BPPV is Still Present

Perform canalith repositioning procedures (Epley or Semont maneuver) rather than prescribing medications 3, 1:

• The Epley maneuver shows 80% vertigo resolution at 24 hours versus 13% with sham treatment 3
• The Semont maneuver demonstrates 94.2% symptom resolution at 6 months versus 57.7% with flunarizine and 34.6% with no treatment 3
• Recurrence rates are 10-18% at 1 year and may reach 36% over time, requiring patient counseling 3

If Ménière's Disease with Persistent Symptoms

Consider intratympanic steroid therapy for refractory Ménière's disease 1.

Lifestyle Modifications

Implement the following evidence-based lifestyle changes 1:

• Limit salt/sodium intake
• Avoid excessive caffeine, alcohol, and nicotine
• Maintain adequate hydration
• Regular exercise
• Sufficient sleep
• Appropriate stress management techniques

Fall Prevention Counseling

Patients with chronic dizziness are at significantly increased risk for falls 3. In elderly patients with chronic vestibular disorders:

• 36.7% carry a diagnosis of BPPV 3
• 53% had fallen at least once in the past year 3
• 29.2% had recurrent falls 3

Provide fall prevention counseling including home safety assessment, activity restrictions, and need for supervision, particularly in elderly and frail patients 3.

Psychological Considerations

Address psychological factors that perpetuate chronic dizziness 5:

• Chronic dizziness frequently leads to panic, anxiety, health preoccupation, and activity avoidance 5
• Anxiety and avoidance can exacerbate symptoms, creating a vicious cycle 5
• Provide detailed explanations of symptom provocation and adaptation processes to enable patients to understand and manage their symptoms 5
• Consider cognitive-behavioral therapy when psychological factors are prominent 2

Follow-Up Protocol

Reassess patients within 1 month after initiating treatment to document resolution or persistence of symptoms 1. This allows for:

• Early identification of treatment failure
• Adjustment of therapeutic approach
• Detection of atypical symptoms (hearing loss, gait disturbance, non-positional vertigo) that warrant further evaluation for underlying vestibular or CNS disorders 3

Common Pitfalls to Avoid

• Do not prescribe vestibular suppressants as long-term therapy 3, 1
• Do not delay vestibular rehabilitation in favor of prolonged medication trials 1
• Do not overlook impeding factors for central compensation (visual, proprioceptive, mobility issues) 2
• Do not assume all chronic dizziness is purely vestibular—rule out neurological gait disorders 2
• Be particularly cautious with vestibular suppressants in elderly patients due to increased cognitive dysfunction, falls, and drug interactions 1