What are the treatment options for dizziness (vertigo)?

Treatment of Dizziness (Vertigo)

For benign paroxysmal positional vertigo (BPPV)—the most common cause of vertigo—perform canalith repositioning procedures (specifically the Epley maneuver for posterior canal BPPV) as first-line treatment, with success rates of 80% after 1-3 treatments and 90-98% with repeat maneuvers if needed. 1, 2

Initial Diagnostic Classification

Before treating, classify the vertigo by timing and triggers 3:

• Triggered episodic vertigo (<1 minute): Suggests BPPV—perform Dix-Hallpike test for posterior canal (85-95% of cases) or supine roll test for lateral canal (10-15% of cases) 2, 3
• Spontaneous episodic vertigo (minutes to hours): Consider Ménière's disease, vestibular migraine, or vertebrobasilar insufficiency 3, 4
• Acute vestibular syndrome (days): May indicate vestibular neuritis, labyrinthitis, or posterior circulation stroke—requires urgent evaluation 3, 5
• Chronic vertigo (weeks to months): Consider persistent postural-perceptual dizziness (PPPD), psychiatric causes, or medication effects 3, 4

Treatment Algorithm by Canal Type

Posterior Canal BPPV (Most Common)

Epley Maneuver 1, 2:

1. Patient sits upright with head turned 45° toward affected ear
2. Rapidly lay patient back to supine head-hanging 20° position for 20-30 seconds
3. Turn head 90° toward unaffected side, hold 20-30 seconds
4. Roll patient onto side with nose pointing down 45°, hold 20-30 seconds
5. Return to upright sitting position

• Success rate: 80% after 1-3 treatments, 90-98% with repeat procedures 2, 6
• Alternative: Semont (Liberatory) maneuver—94.2% resolution at 6 months 2

Horizontal Canal BPPV

For geotropic variant (most common):

• Barbecue Roll (Lempert) Maneuver: Roll patient 360° in sequential 90° steps, holding each position 30 seconds—success rate 50-100% 2
• Alternative: Gufoni maneuver—93% success rate 2

For apogeotropic variant:

• Modified Gufoni Maneuver: Patient lies on affected side for 30 seconds, then turns head 45-60° toward ground for 1-2 minutes 2

Critical Post-Treatment Instructions

Do NOT impose postprocedural restrictions (no head elevation, no sleeping restrictions)—these provide no benefit and may cause unnecessary complications 1, 2

Patients can resume normal activities immediately after treatment 2

Medication Management: What NOT to Do

Avoid routinely prescribing vestibular suppressant medications (meclizine, antihistamines, benzodiazepines) for BPPV treatment 2, 7:

• No evidence of effectiveness as definitive treatment 2
• Cause significant adverse effects: drowsiness, cognitive deficits, increased fall risk (especially in elderly) 2
• Interfere with central compensation mechanisms 2
• Decrease diagnostic sensitivity during Dix-Hallpike testing 2

Limited exception: May consider short-term use only for severe nausea/vomiting in severely symptomatic patients refusing other treatment 2

When Treatment Fails

If symptoms persist after initial treatment, reassess within 1 month 2, 8:

1. Repeat diagnostic test to confirm persistent BPPV—repeat CRP achieves 90-98% success 2
2. Check for canal conversion (occurs in 6-7% of cases)—posterior may convert to lateral canal or vice versa 2
3. Evaluate for multiple canal involvement or bilateral BPPV 1, 2
4. Rule out coexisting vestibular dysfunction if symptoms occur with general head movements or spontaneously 2
5. Consider CNS disorders masquerading as BPPV, especially with atypical features 1, 2

Adjunctive Vestibular Rehabilitation

Offer vestibular rehabilitation therapy (VRT) as adjunct, not substitute for canalith repositioning 2:

• Particularly beneficial for patients with residual dizziness, postural instability, or heightened fall risk after successful CRP 2
• Reduces recurrence rates by approximately 50% 2
• Patients treated with CRP plus VRT show significantly improved gait stability compared to CRP alone 2

Brandt-Daroff exercises: Less effective alternative (24% vs 71-74% success at 1 week compared to repositioning maneuvers)—reserve for patients with contraindications to CRP 2, 6

Self-Treatment Options

Self-administered Epley maneuver can be taught to motivated patients after at least one properly performed in-office treatment 1, 2:

• 64% improvement rate vs 23% with Brandt-Daroff exercises 2
• More effective than self-treatment with Brandt-Daroff exercises 1, 2

Special Populations Requiring Modified Approach

Assess all patients before treatment for 1, 2:

• Severe cervical stenosis or radiculopathy: Consider Brandt-Daroff exercises instead of CRP 2
• Morbid obesity, Down syndrome, Paget's disease: May need specialized examination tables or modified approaches 2
• Elderly with fall history: Require immediate fall risk counseling—BPPV increases fall risk 12-fold 2
• CNS disorders (multiple sclerosis, traumatic brain injury): May require repeated treatments (up to 67% vs 14% in non-traumatic cases) 1

When to Order Imaging

Do NOT obtain imaging for typical BPPV with positive Dix-Hallpike test 1, 8

Order urgent MRI brain with contrast if 3, 8:

• Additional neurological symptoms beyond vertigo
• Atypical nystagmus patterns
• Severe postural instability
• Focal neurologic deficits
• Failure to respond to appropriate treatment after 2-3 properly performed maneuvers

Common Pitfalls to Avoid

• Assuming normal neurologic exam excludes stroke: 75-80% of posterior circulation strokes causing vertigo may lack focal deficits initially 3
• Misdiagnosing central causes as BPPV: CNS disorders found in 3% of treatment failures 3
• Not moving patient quickly enough during maneuvers reduces effectiveness 2
• Failing to reassess after initial treatment: Always follow up within 1 month to confirm resolution 2, 8
• Prescribing vestibular suppressants as primary treatment: No evidence of benefit and significant harm potential 2, 7

Recurrence Management

BPPV has high recurrence rates: 10-18% at 1 year, 30-50% at 5 years 2

Each recurrence should be treated with repeat CRP, which maintains the same high success rates 2