What are the treatments for dizziness?

Treatment of Dizziness

The treatment of dizziness depends critically on identifying the underlying cause, with canalith repositioning procedures (Epley or Semont maneuvers) as first-line for BPPV, short-term vestibular suppressants only for acute severe symptoms in non-BPPV peripheral vertigo, and vestibular rehabilitation for long-term recovery—medications should never be used as primary treatment for BPPV and only briefly for symptom control in other vestibular disorders. 1, 2, 3

Diagnostic Approach First

Before treating dizziness, you must establish the specific diagnosis:

• Perform the Dix-Hallpike maneuver to diagnose posterior canal BPPV by bringing the patient from upright to supine with head turned 45° to one side and neck extended 20°, looking for torsional upbeating nystagmus 1
• Assess timing and triggers: episodic triggered vertigo suggests BPPV, spontaneous attacks suggest Ménière's disease or vestibular neuritis 4, 5
• Use HINTS examination (head impulse, nystagmus, test of skew) when central causes are suspected to distinguish life-threatening central vertigo from peripheral causes 4

Treatment Algorithm by Diagnosis

For BPPV (Most Common Cause)

Canalith repositioning procedures are the definitive treatment with 78.6-93.3% success rates, vastly superior to medication (30.8% improvement). 3

Posterior Canal BPPV:

• Perform Epley maneuver as first-line treatment, achieving approximately 80% success with only 1-3 treatments 3
• Alternative: Semont maneuver has similar efficacy if Epley cannot be performed 3
• Do NOT use meclizine or other vestibular suppressants as primary treatment—they are explicitly not recommended and do not address the underlying cause 2, 3
• Do NOT impose post-procedural restrictions after canalith repositioning—these are not beneficial 1

Lateral Canal BPPV:

• Use barbecue roll maneuver OR Gufoni maneuver for geotropic type, with 50-100% response rates 1
• For geotropic type: Gufoni maneuver showed 93% success vs 81% for barbecue roll with prolonged positioning 1
• Each position should be held 15-30 seconds or until nystagmus stops 1

Managing Nausea During Repositioning:

• Pre-medicate high-risk patients (history of motion sickness) with meclizine 25-50 mg or prochlorperazine 30-60 minutes before the procedure 3
• Counsel patients beforehand that intense vertigo lasting up to 60 seconds is expected and normal 3
• Move slowly between positions if severe nausea develops 3

For Non-BPPV Peripheral Vertigo

Vestibular suppressants should only be used short-term for severe acute symptoms, not as definitive treatment. 2, 3

Medication Options (Short-term Only):

Meclizine:

• Dosage: 25-100 mg daily in divided doses, used primarily as-needed (PRN) rather than scheduled 2, 3, 6
• Works by suppressing the central emetic center 2
• Use only for severe autonomic symptoms (nausea/vomiting), not as primary treatment 2
• Major caution: Causes drowsiness, cognitive deficits, increased fall risk especially in elderly, and interferes with vestibular compensation if used long-term 2, 3, 6

Prochlorperazine:

• Dosage: 5-10 mg orally or IV, maximum three doses per 24 hours 2
• Use only for severe nausea/vomiting, not for vertigo itself 2
• Avoid in patients with CNS depression or using adrenergic blockers 2

Benzodiazepines (e.g., diazepam/Valium):

• Use only for short-term management of severe vertigo with significant anxiety component 2, 7
• Particularly helpful for psychological anxiety secondary to vertigo 7
• Significant risk of dependence—limit duration strictly 7
• Causes drowsiness, cognitive deficits, fall risk 7

Ménière's Disease Specific:

• Offer vestibular suppressants only during acute attacks, not continuously 1, 2, 3
• Dietary modifications: Restrict sodium to ≤1500-2300 mg/day (American Heart Association guidelines) 1
• Avoid caffeine and alcohol which may trigger attacks 1, 2
• Consider diuretics for long-term prevention 3

Vestibular Rehabilitation

Transition from medications to vestibular rehabilitation as soon as tolerable for long-term recovery. 2, 3

• Effective for many peripheral and central causes of dizziness 5
• Promotes central compensation which medications can interfere with 2
• Should be initiated once acute severe symptoms subside 2

Critical Pitfalls to Avoid

Never use vestibular suppressants long-term:

• They interfere with central vestibular compensation 2
• Increase fall risk, especially in elderly (independent risk factor) 2
• Cause anticholinergic side effects: drowsiness, cognitive deficits, dry mouth, blurred vision, urinary retention 2, 6

Never use meclizine as primary treatment for BPPV:

• No evidence of efficacy for BPPV 2, 3
• Delays definitive treatment with repositioning maneuvers 3
• Studies show canalith repositioning is vastly superior 3

In elderly patients with dizziness:

• Avoid routine meclizine prescription due to high fall risk and anticholinergic burden 3
• Consider observation alone for BPPV as it often resolves spontaneously 3
• Polypharmacy concerns and drug-drug interactions are significant 3

Follow-up Protocol

Reassess within 1 month after initial treatment to document resolution or persistence of symptoms 1, 2, 3

• If symptoms persist, evaluate for unresolved BPPV or underlying peripheral/central nervous system disorders 1
• Discontinue vestibular suppressants as soon as possible 3
• Transition to vestibular rehabilitation when appropriate 2, 3

Lifestyle Modifications (Adjunctive)

Implement alongside medical treatment:

• Limit sodium intake (especially for Ménière's disease) 1, 2, 3
• Avoid excessive caffeine, alcohol, and nicotine 1, 2, 3
• Maintain adequate hydration, regular exercise, sufficient sleep 2, 3
• Manage stress appropriately 2, 3

Patient Education

Educate patients on:

• Impact of dizziness on safety (fall risk, driving restrictions while symptomatic) 1
• Potential for BPPV recurrence 1
• Importance of follow-up 1
• Expected timeline: repositioning procedures work quickly (1-3 treatments), while vestibular rehabilitation requires weeks to months 3