What is the treatment for dizziness?

Treatment of Dizziness

The treatment for dizziness depends entirely on the underlying cause, which must be identified through focused history on timing and triggers: for benign paroxysmal positional vertigo (BPPV)—the most common cause—perform canalith repositioning procedures (Epley maneuver) as first-line treatment with 80% success rates, while vestibular suppressant medications like meclizine should NOT be used routinely and are reserved only for short-term management of severe nausea in select cases. 1, 2

Diagnostic Approach: Identify the Cause First

Before treating dizziness, you must categorize it based on timing and triggers, not the patient's vague descriptions 3, 4:

• Brief episodic vertigo (seconds to minutes, triggered by head movements): Likely BPPV 3
• Acute persistent vertigo (days to weeks, constant): Consider vestibular neuritis, labyrinthitis, or stroke 3, 5
• Recurrent spontaneous episodes: Consider Ménière's disease or vestibular migraine 2, 5
• Chronic continuous dizziness: Consider medication side effects, psychiatric causes, or central pathology 6, 5

Essential Physical Examination

• Dix-Hallpike maneuver: Gold standard for diagnosing BPPV—positive test shows 5-20 second latency, torsional upbeating nystagmus, and symptoms resolving within 60 seconds 1, 3
• HINTS examination (Head-Impulse, Nystagmus, Test of Skew): For acute persistent vertigo, this is 100% sensitive for detecting stroke when performed by trained practitioners (vs. 46% for early MRI) 3
• Orthostatic blood pressure: Rule out presyncope from hypotension 5, 4

Treatment Algorithm by Diagnosis

For BPPV (Most Common Cause)

Canalith repositioning procedures are the definitive treatment—NOT medications 1, 2:

• Epley maneuver: 80% success after 1-3 treatments, 90-98% after repeat maneuvers 2, 3
• Semont maneuver: Alternative with similar efficacy (94.2% resolution at 6 months) 6
• Barbecue roll or Gufoni maneuver: For lateral canal BPPV 1

Do NOT prescribe meclizine or other vestibular suppressants for BPPV 1, 2:

• Medications show only 30.8% improvement vs. 78.6-93.3% with repositioning procedures 2, 6
• Patients who received repositioning alone recovered faster than those given concurrent medications 2
• Vestibular suppressants can interfere with central compensation and prolong symptoms 6

Limited exceptions for medication use in BPPV 2:

• Prophylaxis for patients with history of severe nausea during prior repositioning attempts
• Short-term management of severe nausea/vomiting in highly symptomatic patients refusing other treatment
• Use antiemetics (ondansetron, metoclopramide) for nausea relief only—never as primary BPPV treatment 2

For Ménière's Disease

• Dietary modifications: Salt restriction (most important) 2
• Diuretics: For prevention of flare-ups 2
• Vestibular suppressants: Limited course for acute attacks only 2
• Intratympanic steroids or gentamicin: For refractory cases 6, 5

For Vestibular Neuritis/Labyrinthitis

• Corticosteroids: For vestibular neuritis within first 72 hours 5
• Vestibular rehabilitation: Primary long-term treatment 2, 6
• Short-term vestibular suppressants: Only for severe acute symptoms (3-5 days maximum) 2

For Vestibular Migraine

• Migraine prophylaxis: First-line treatment 3
• Lifestyle modifications: Trigger avoidance, stress management 2

Vestibular Rehabilitation: When and Why

Vestibular rehabilitation is indicated when 2, 6:

• Balance and motion tolerance don't improve after initial treatment
• Residual dizziness persists after successful BPPV repositioning
• Elderly patients, those with CNS disorders, or high fall risk
• Chronic vestibular conditions requiring central compensation

Vestibular rehabilitation significantly improves gait stability compared to medication alone 6 and includes habituation exercises, gaze stabilization, balance retraining, and fall prevention strategies 3.

Medication Use: Critical Cautions

When Vestibular Suppressants May Be Considered (Rarely)

Meclizine (25-100 mg daily in divided doses) 2, 7:

• Use as-needed only, not scheduled, to avoid interfering with vestibular compensation 2
• Reserved for short-term management of severe symptoms in non-BPPV vertigo 2
• Never use routinely or as primary treatment 1, 2

Significant Harms of Vestibular Suppressants

All vestibular suppressants cause 2, 6:

• Drowsiness and cognitive deficits interfering with driving 2, 7
• Significantly increased fall risk, especially in elderly patients 2, 6
• Anticholinergic effects: dry mouth, blurred vision, urinary retention 2, 7
• Interference with central compensation, potentially prolonging symptoms 6

Special concern in elderly patients 2, 6:

• Benzodiazepines are independent risk factors for falls and should be discontinued 6
• Meclizine is considered eligible for deprescribing in frail elderly 6
• Polypharmacy increases fall risk exponentially 6

Red Flags Requiring Urgent Evaluation

Immediate imaging and neurologic consultation needed for 3:

• Focal neurological deficits
• Sudden hearing loss
• Inability to stand or walk
• New severe headache
• Downbeating nystagmus or other central nystagmus patterns
• HINTS examination suggesting central cause

MRI brain without contrast is preferred over CT (CT has <1% diagnostic yield for isolated dizziness and misses most posterior circulation strokes) 3.

Follow-Up Protocol

Reassess all patients within 1 month after initial treatment 1, 2, 6:

• Document resolution or persistence of symptoms
• Discontinue vestibular suppressants as soon as possible
• Transition to vestibular rehabilitation when appropriate
• Counsel about recurrence risk (10-18% at 1 year for BPPV) 6

Critical Pitfalls to Avoid

• Don't rely on patient descriptions of "spinning" vs. "lightheadedness"—focus on timing and triggers instead 3
• Don't prescribe meclizine for BPPV—it's ineffective and delays proper treatment 1, 2
• Don't assume normal neurologic exam excludes stroke—75-80% of posterior circulation strokes have no focal deficits 3
• Don't order routine imaging for isolated dizziness without red flags 3
• Don't use vestibular suppressants long-term—they interfere with compensation 6
• Don't skip fall prevention counseling in elderly patients (53% had fallen in past year) 6