What are the management options for dizziness?

Management of Dizziness

Initial Diagnostic Approach

Classify dizziness by timing and triggers rather than patient's subjective description, as patients struggle to accurately describe symptom quality but can reliably identify when and what provokes their symptoms. 1, 2

Key History Elements to Elicit

• Timing: Episodic vs. continuous symptoms 3
• Triggers: Head motion, position changes, standing up, or no identifiable trigger 2, 3
• Associated symptoms: Hearing loss, tinnitus, neurological symptoms, cardiac symptoms 4, 3
• Duration: Seconds (BPPV), minutes to hours (vestibular migraine), hours (Meniere's), days (vestibular neuritis) 1, 5

Essential Physical Examination

• Dix-Hallpike maneuver for posterior canal BPPV diagnosis 6, 1
• Supine roll test if Dix-Hallpike is negative to assess lateral canal BPPV 6, 1
• Orthostatic vital signs to evaluate for presyncope 2, 3
• HINTS examination (head-impulse, nystagmus, test of skew) when central etiology suspected 2
• Full neurologic examination to identify central causes 2, 3

Treatment of BPPV (Most Common Cause)

Perform the Canalith Repositioning Procedure (Epley maneuver) immediately for posterior canal BPPV, which achieves 90-98% success rates and is the definitive treatment. 1

Posterior Canal BPPV Management

• Particle repositioning maneuver (Epley maneuver) is the treatment of choice 6, 1
• Reassess within 1 month after initial treatment to document resolution or persistence 1
• Repeat repositioning if symptoms persist—multiple sessions are commonly needed 6
• Consider lateral canal involvement or canal conversion if treatment fails 1

Lateral Canal BPPV Management

• Gufoni maneuver or barbecue roll maneuver with success rates of 86-100% 1
• Diagnosed via supine roll test when Dix-Hallpike is negative 6, 1

What NOT to Do for BPPV

• Do NOT routinely prescribe vestibular suppressant medications (antihistamines, benzodiazepines) as they do not address the underlying cause and delay compensation 6, 1
• Do NOT obtain radiographic imaging or vestibular testing unless diagnosis is uncertain or additional neurological symptoms are present 6
• Meclizine may be used short-term only for severe nausea/vomiting, not as primary treatment 1, 7

Patient Counseling for BPPV

• Recurrence risk is 15% per year, reaching 36-50% at 5 years 6
• Fall risk is significantly elevated—counsel on home safety, particularly in elderly patients 6
• Posttraumatic BPPV requires up to 67% repeated treatments vs. 14% for nontraumatic cases 6
• Residual dizziness may persist for days to weeks even after successful repositioning 6

Treatment of Vestibular Migraine

Initiate lifestyle modifications first, followed by preventive medications (beta blockers, topiramate, or candesartan) when symptoms occur ≥2 days per month despite optimized acute treatment. 5

Acute Management

• Vestibular suppressants for acute attacks only, not long-term use 5
• Triptans for concurrent headache 5
• Antiemetics (diphenhydramine, meclizine) to ameliorate acute symptoms 5

Preventive Treatment

• First-line: Beta blockers (atenolol, propranolol), topiramate, or candesartan 5
• Third-line: CGRP monoclonal antibodies (erenumab, fremanezumab, galcanezumab, eptinezumab) 5
• Assess efficacy after 2-3 months at therapeutic dose 5
• Consider pausing treatment after 6-12 months of successful control 5

Lifestyle Modifications

• Limit salt/sodium intake, avoid excessive caffeine, alcohol, nicotine 5
• Maintain regular sleep patterns and adequate hydration 5
• Stress management and regular exercise 5
• Identify and manage allergies 5

Treatment of Meniere's Disease

• Salt restriction and diuretics for long-term management 1, 3
• Short-term vestibular suppressants during acute attacks only 1
• Intratympanic dexamethasone or gentamicin for refractory cases 4

Treatment of Vestibular Neuritis

• Steroids in acute phase 4, 3
• Vestibular rehabilitation as primary treatment 1, 3
• Vestibular suppressants for symptom relief during acute phase only, then discontinue 3

Vestibular Rehabilitation

Prescribe vestibular rehabilitation therapy for persistent dizziness from any vestibular cause, as it facilitates central compensation and improves outcomes. 1, 2

• Effective for peripheral and central etiologies 2
• Particularly important for vestibular neuritis 3
• Helps with residual symptoms after BPPV treatment 6

Management of Treatment Failures

When to Reassess

• Persistent symptoms after 1 month of initial treatment 1
• Atypical symptoms: subjective hearing loss, gait disturbance, nonpositional vertigo 6
• Treatment failure after 2-3 repositioning attempts 6

Evaluation for Treatment Failure

• Repeat positional testing to assess for unresolved BPPV or canal conversion 1
• Thorough neurological examination to identify CNS disorders 6
• MRI of brain and posterior fossa if symptoms are atypical or refractory to treatment 6
• Consider bilateral or multicanal BPPV requiring multiple treatments 6

Red Flags Requiring Urgent Evaluation

• Abnormal cranial nerve findings 6
• Visual disturbances 6
• Severe headache 6
• Gait disturbance 6
• Associated neurological symptoms 6

Special Populations

Elderly and High-Risk Patients

• Assess for impaired mobility, balance disorders, lack of home support, and increased fall risk 6
• Home safety assessment and activity restrictions until BPPV resolves 6
• Consider home assistance or temporary nursing home placement for severe, chronic, or refractory cases 6
• Avoid vestibular suppressants due to drowsiness, cognitive deficits, and increased fall risk 1

Posttraumatic BPPV

• Elicit history of head trauma as it predicts more refractory disease 6
• Expect higher recurrence rates and need for repeated treatments 6
• May be bilateral requiring specialized treatment 6

Patients with CNS Disorders

• Multiple sclerosis patients with acute vertigo may have BPPV responsive to standard treatment 6
• Conventional diagnostic and treatment methods remain effective despite underlying CNS disorder 6

Critical Pitfalls to Avoid

• Do NOT use vestibular suppressants as primary BPPV treatment—they prevent central compensation 6, 1
• Do NOT order imaging or vestibular testing for straightforward BPPV cases 6
• Do NOT abandon treatment prematurely—multiple repositioning sessions are often needed 6
• Do NOT miss central causes—perform HINTS examination when indicated 2
• Do NOT overlook fall risk counseling, especially in elderly patients 6