What are the treatments for benign causes of dizziness?

Treatment of Benign Causes of Dizziness

For benign paroxysmal positional vertigo (BPPV), the most common benign cause of dizziness, perform canalith repositioning procedures (CRPs) as first-line treatment and avoid vestibular suppressant medications. 1, 2, 3

First-Line Treatment by Canal Type

Posterior Canal BPPV (85-95% of cases)

• Perform the Epley maneuver, which achieves 80% success with 1-3 treatments and 90-98% success with repeat maneuvers if needed 2, 3
• The technique involves: patient seated with head turned 45° toward affected ear, rapidly moved to supine head-hanging 20° position for 20-30 seconds, head turned 90° to unaffected side, head and body turned another 90° (face down), then return to sitting 2, 3
• Alternative option: Semont (Liberatory) maneuver, with 94.2% resolution at 6 months and 71% at 1 week 2

Horizontal (Lateral) Canal BPPV (10-15% of cases)

• For geotropic variant: Barbecue Roll (Lempert) maneuver (50-100% success) or Gufoni maneuver (93% success) 2, 3
• For apogeotropic variant: Modified Gufoni maneuver (patient lies on affected side) 2

Critical Post-Treatment Instructions

• Do NOT impose postprocedural restrictions after CRP—patients can resume normal activities immediately 1, 2, 3
• This recommendation is based on strong evidence showing restrictions provide no benefit and may cause unnecessary complications 2
• Reassess patients within 1 month to confirm symptom resolution 1, 3

Medication Management: What NOT to Do

Avoid routinely prescribing vestibular suppressant medications (meclizine, antihistamines, benzodiazepines) for BPPV treatment 1, 2, 3

The evidence is clear on this point:

• No evidence shows these medications are effective as definitive treatment for BPPV 1
• They cause significant adverse effects including drowsiness, cognitive deficits, and increased fall risk (especially in elderly) 2
• They interfere with central compensation mechanisms and decrease diagnostic sensitivity during Dix-Hallpike testing 2
• One controlled trial comparing diazepam, lorazepam, and placebo showed no additional relief in drug treatment arms 1

Limited exception: Consider vestibular suppressants only for short-term management of severe nausea/vomiting in severely symptomatic patients refusing other treatment or requiring prophylaxis immediately before/after CRP 1, 3

Self-Treatment Options

• Teach motivated patients self-administered Epley maneuver after at least one properly performed in-office treatment 2, 3
• Self-administered CRP shows 64% improvement vs. only 23% with Brandt-Daroff exercises 2
• Brandt-Daroff exercises are significantly less effective than CRP (24% vs. 80.5% success at 1 week) but may be used for patients with physical limitations 2

Vestibular Rehabilitation Therapy (VRT)

• Offer VRT as adjunctive therapy, not as substitute for CRP 1, 2
• VRT is particularly beneficial for patients with residual dizziness, postural instability, or heightened fall risk after successful CRP 1
• Patients treated with CRP plus VR exercises show significantly improved gait stability compared to CRP alone 1
• VRT includes habituation exercises, adaptation exercises for gaze stabilization, and balance training 2

Management of Treatment Failures

If symptoms persist after initial treatment, follow this algorithm 2, 3:

1. Repeat diagnostic testing (Dix-Hallpike or supine roll test) to confirm persistent BPPV
2. Perform additional repositioning maneuvers—repeat CRPs achieve 90-98% success 2
3. Check for canal conversion (occurs in 6-7% of cases during treatment) 2, 3
4. Evaluate for multiple canal involvement or bilateral BPPV 2
5. Rule out coexisting vestibular pathology if symptoms occur with general head movements or spontaneously 2
6. Consider CNS disorders masquerading as BPPV if atypical features present 2

Special Populations and Risk Factors

Assess all patients before treatment for 1, 2:

• Impaired mobility or balance
• CNS disorders
• Lack of home support
• Increased fall risk

Elderly patients warrant particular attention 2:

• 9% of elderly patients in geriatric clinics have unrecognized BPPV 2
• Three-quarters of elderly with BPPV have fallen within the previous 3 months 2
• Higher risk for falls, depression, and impaired daily activities 1

Patients with physical limitations (cervical stenosis, severe rheumatoid arthritis, cervical radiculopathies) may need specialized examination tables, modified approaches, or may be better candidates for Brandt-Daroff exercises than CRP 2

Common Pitfalls to Avoid

• Failing to identify the affected canal and variant before treatment leads to ineffective therapy 2
• Not moving the patient quickly enough during maneuvers reduces effectiveness 2
• Prescribing medications instead of performing repositioning maneuvers is the most common error 3
• Failing to reassess patients after initial treatment misses persistent symptoms requiring additional intervention 2, 3
• Missing canal conversions during treatment requires switching to appropriate maneuver for newly affected canal 2

When Imaging/Testing is NOT Needed

Do NOT order radiographic imaging or vestibular testing in patients who meet clinical criteria for BPPV unless the diagnosis is uncertain or additional symptoms unrelated to BPPV are present 1, 2