What are the management and treatment options for a patient experiencing dizziness?

Management of Dizziness

Immediate Diagnostic Approach

The first priority is to determine if the dizziness is benign paroxysmal positional vertigo (BPPV), which accounts for the majority of peripheral vertigo cases and has highly effective office-based treatment. 1

Perform Bedside Positional Testing

• Execute the Dix-Hallpike maneuver to diagnose posterior canal BPPV (85-95% of BPPV cases), looking for torsional upbeating nystagmus with vertigo 2
• If the Dix-Hallpike is negative but positional dizziness persists, perform the supine roll test to assess for lateral semicircular canal BPPV (10-15% of cases), observing for horizontal nystagmus 2
• Do not obtain radiographic imaging or vestibular testing unless the diagnosis is uncertain or additional neurological symptoms are present 1

Treatment Based on Diagnosis

If BPPV is Confirmed (Positive Dix-Hallpike or Supine Roll Test)

Perform canalith repositioning procedures immediately—this is the definitive first-line treatment with 80% success after 1-3 treatments and 90-98% success with repeat maneuvers. 2

For Posterior Canal BPPV (Most Common)

• Execute the Epley maneuver: patient sits upright with head turned 45° toward affected ear, rapidly lay back to supine head-hanging 20° position for 20-30 seconds, turn head 90° to opposite side for 20-30 seconds, roll patient onto shoulder while maintaining head position for 20-30 seconds, return to sitting 1, 2
• Alternative: Semont maneuver (94.2% resolution at 6 months) 2

For Lateral Canal BPPV

• Geotropic variant: Use Gufoni maneuver (93% success) or Barbecue Roll maneuver (50-100% success) 1, 2
• Apogeotropic variant: Use modified Gufoni maneuver (patient lies on affected side first) 1, 2

Critical Post-Treatment Instructions

• Patients can resume normal activities immediately—postprocedural restrictions provide no benefit and may cause unnecessary complications 2
• Do NOT prescribe vestibular suppressant medications (meclizine, antihistamines, benzodiazepines) as they are ineffective for BPPV treatment, interfere with central compensation, and cause drowsiness, cognitive deficits, and increased fall risk 3, 2, 4

If BPPV is Not Confirmed or Symptoms Persist

Assess for Modifying Factors

• Evaluate for impaired mobility/balance, CNS disorders, lack of home support, and increased fall risk before determining treatment approach 1
• Elderly patients with BPPV have 53% one-year fall rate and 29.2% recurrent fall rate—this population requires particular attention 1, 3

Consider Vestibular Rehabilitation Therapy

• Offer VRT as primary intervention for persistent dizziness that has failed medication trials or as adjunct to repositioning procedures for residual symptoms 1, 3
• VRT includes habituation exercises, gaze stabilization, balance retraining, and fall prevention strategies 1
• Patients treated with repositioning procedures plus VRT show significantly improved gait stability compared to repositioning alone 1, 3

Limited Role for Medications

• Vestibular suppressants should only be used short-term (days, not weeks) for severe nausea/vomiting in acutely symptomatic patients 3, 2
• Meclizine dosing per FDA label: 25-100 mg daily in divided doses, but recognize this is only for symptom management, not definitive treatment 4
• Long-term vestibular suppressant use interferes with central compensation and may prolong symptoms 3

Follow-Up Protocol

• Reassess all patients within 1 month to document resolution or persistence of symptoms 3, 2
• If symptoms persist after initial treatment: repeat diagnostic testing, perform additional repositioning maneuvers (90-98% success with repeat attempts), check for canal conversion (occurs in 6-7% of cases), evaluate for multiple canal involvement, and rule out coexisting vestibular or CNS disorders 2

Patient Education and Safety Counseling

• Educate patients about 10-18% recurrence rate at 1 year (may reach 36% over time), allowing earlier recognition and treatment of recurrent episodes 1
• Counsel about increased fall risk, particularly in elderly patients—36.7% of elderly with chronic vestibular disorders have BPPV 1, 3
• Provide fall prevention strategies including home safety assessment and activity modifications during symptomatic periods 1
• Teach self-administered Epley maneuver to motivated patients (64% improvement rate vs 23% with Brandt-Daroff exercises) 2

Common Pitfalls to Avoid

• Do not prescribe vestibular suppressants as primary or long-term treatment—they are ineffective for BPPV and cause significant adverse effects including increased fall risk, especially in elderly patients 3, 2, 4
• Do not impose postprocedural restrictions after canalith repositioning procedures—strong evidence shows no benefit 2
• Do not order imaging or vestibular testing for straightforward BPPV cases—diagnosis is clinical based on positional maneuvers 1, 2
• Do not assume treatment failure after one attempt—repeat maneuvers achieve 90-98% success rates 2