What is the best management plan for an elderly male with persistent dizziness on Betahistine (Serc), with a diet high in red meat and fatty foods, and no history of hypertension?

Management of Persistent Dizziness in Elderly Male on Betahistine

This patient requires immediate discontinuation of betahistine and initiation of vestibular rehabilitation therapy, as betahistine is not indicated for BPPV and particle repositioning maneuvers are vastly superior (78.6%-93.3% improvement vs 30.8% with medication alone). 1, 2

Diagnostic Reassessment Required

The initial diagnosis of BPPV needs confirmation through proper positional testing (Dix-Hallpike or supine roll test), as the patient reports persistent symptoms despite betahistine therapy. 1, 3

Key diagnostic considerations:

• Confirm true BPPV vs other vestibular disorders: The patient describes "dizziness" rather than specific rotatory vertigo, which may indicate misdiagnosis. 4
• Rule out central causes: Normal neurological exam is reassuring, but persistent symptoms warrant consideration of vestibular migraine, vestibular neuritis, or early Ménière's disease. 4, 3
• Elderly patients with long-standing vestibular disorders may present with "vague dizziness" rather than frank vertigo. 4

Why Betahistine Should Be Discontinued

Betahistine is NOT recommended for BPPV treatment. 1, 2 The American Academy of Otolaryngology-Head and Neck Surgery explicitly states that neither betahistine nor cinnarizine is routinely recommended for BPPV. 1

Evidence against betahistine in BPPV:

• Particle repositioning maneuvers demonstrate 78.6%-93.3% improvement versus only 30.8% with medication alone. 1, 2
• Patients who underwent repositioning maneuvers alone recovered faster than those who received concurrent vestibular suppressants. 3
• The Epley maneuver shows 80% vertigo resolution at 24 hours versus 13% with sham treatment. 3
• Recent high-quality trials show no significant difference between betahistine and placebo for vertigo control in non-Ménière's conditions. 3

Betahistine is ONLY indicated for:

• Definite or probable Ménière's disease (characterized by 2+ episodes of vertigo lasting 20 minutes to 12 hours AND fluctuating sensorineural hearing loss, tinnitus, or aural pressure). 1
• This patient has NO hearing loss, tinnitus, or aural fullness documented. 1

Correct Treatment Approach for BPPV

Primary intervention: Canalith repositioning procedures

• The Epley maneuver for posterior canal BPPV shows 80% resolution at 24 hours. 3
• The Semont maneuver demonstrates 94.2% symptom resolution at 6 months versus 57.7% with flunarizine and 34.6% with no treatment. 3
• Perform appropriate repositioning maneuver based on affected canal (posterior, horizontal, or anterior). 1, 3

If symptoms persist after successful repositioning:

• Initiate vestibular rehabilitation therapy (VRT) for residual dizziness. 1, 3
• VRT significantly improves overall gait stability compared to medication alone. 3
• VRT promotes central compensation and long-term recovery. 3
• Increased balance performance is achieved only when movement/habituation-based vestibular rehabilitation is administered, not with repositioning procedures alone. 3

Fall Risk Assessment Critical in This Elderly Patient

This 78-year-old male is at significantly increased risk for falls:

• 36.7% of elderly patients with chronic vestibular disorders carry a diagnosis of BPPV. 3
• 53% of elderly patients with chronic vestibular disorders had fallen at least once in the past year. 3
• 29.2% had recurrent falls. 3
• Vestibular suppressant medications significantly increase fall risk, especially in elderly patients. 1, 3

Provide comprehensive fall prevention counseling:

• Home safety assessment (remove tripping hazards, improve lighting, install grab bars). 3
• Activity restrictions during acute symptomatic periods. 3
• Need for supervision, particularly in this frail elderly patient. 3

Cardiovascular and Dietary Considerations

The patient's high-fat diet (red meat, balut, quail eggs) requires counseling:

• While not directly related to BPPV, cardiovascular risk factors should be addressed. 3
• Blood pressure 120/60 is acceptable, but dietary modification may prevent future cardiovascular complications. 3

Lifestyle modifications recommended by the American Academy of Otolaryngology-Head and Neck Surgery:

• Limiting salt/sodium intake. 3
• Avoiding excessive caffeine, alcohol, and nicotine (patient already stopped smoking—reinforce this). 3
• Maintaining adequate hydration. 3
• Regular exercise (which also helps with vestibular compensation). 3
• Sufficient sleep and stress management. 3

Follow-Up Protocol

Reassess within 1 month after initiating repositioning maneuvers to document resolution or persistence of symptoms. 3

Monitor for:

• Complete resolution of positional vertigo. 3
• Development of residual dizziness requiring VRT. 3
• Recurrence (10-18% at 1 year, may reach 36% over time). 3
• 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 continue betahistine for BPPV—it is ineffective and delays proper treatment. 1, 2
• Do NOT prescribe vestibular suppressants as long-term therapy. 3
• Do NOT add prochlorperazine or other vestibular suppressants, as they interfere with central compensation and increase fall risk. 1, 3
• Do NOT use benzodiazepines—they are a significant independent risk factor for falls and should be discontinued if present. 3
• Avoid polypharmacy, as the risk of falls increases in patients taking multiple medications. 3

If BPPV Diagnosis Is Incorrect

If reassessment reveals Ménière's disease (not BPPV):

• Betahistine 48 mg daily would be appropriate for at least 3 months. 1
• Higher doses (144 mg/day) have not shown significant improvement compared to lower doses. 1
• If no improvement after 6-9 months, continued betahistine therapy is unlikely to be beneficial. 1, 2

If reassessment reveals vestibular neuritis or other peripheral vestibular disorder:

• Short-term vestibular suppressants (3-5 days maximum) for severe acute symptoms only. 3
• Early initiation of VRT to promote central compensation. 3, 5