What is the appropriate treatment, dose, and frequency for a patient experiencing dizziness, considering potential underlying causes such as vestibular migraine, benign paroxysmal positional vertigo (BPPV), cardiovascular disease, or neurological disorders?

Treatment of Dizziness: Diagnosis-Specific Dosing and Frequency

Treatment of dizziness depends entirely on the underlying cause, with benign paroxysmal positional vertigo (BPPV) requiring canalith repositioning procedures rather than medication, while vestibular neuritis and Ménière's disease benefit from specific pharmacologic interventions. 1

Step 1: Categorize by Timing and Triggers (Not Symptom Quality)

The American Academy of Otolaryngology-Head and Neck Surgery emphasizes that focusing on timing and triggers is more diagnostically valuable than the patient's subjective description of their dizziness 2, 3, 4:

• Triggered episodic (<1 minute): Brief episodes triggered by head position changes → likely BPPV 2, 3
• Spontaneous episodic (minutes to hours): Episodes without positional triggers → consider vestibular migraine, Ménière's disease, or vertebrobasilar insufficiency 2, 4
• Acute persistent (days to weeks): Constant symptoms → vestibular neuritis, labyrinthitis, or stroke 2, 3
• Chronic (weeks to months): Persistent symptoms → medication side effects, anxiety disorders, or posterior fossa masses 2, 3

Step 2: Perform Targeted Physical Examination

For Triggered Episodic Symptoms (Suspected BPPV)

Perform the Dix-Hallpike maneuver to confirm diagnosis 1, 2, 4:

• Positive findings: 5-20 second latency, torsional upbeating nystagmus toward affected ear, symptoms resolve within 60 seconds 2, 4
• Red flags requiring imaging: Purely vertical nystagmus without torsional component, immediate onset without latency, or persistent nystagmus 1, 2

For Acute Persistent Symptoms

Perform the HINTS examination (Head Impulse, Nystagmus, Test of Skew) if trained, as it has 100% sensitivity for detecting posterior circulation stroke versus 46% for early MRI 3, 4. However, this examination is unreliable when performed by non-experts 3.

Critical pitfall: 75-80% of patients with posterior circulation stroke have NO focal neurologic deficits, so a normal neurologic exam does NOT exclude stroke 3, 4.

Step 3: Treatment Based on Diagnosis

BPPV (Most Common Cause - 42% of Cases)

Treatment: Canalith repositioning procedures (Epley maneuver) 2, 4, 5, 6

• Success rate: 80% after 1-3 treatments, 90-98% after repeat maneuvers 4
• Frequency: Repeat immediately if first attempt unsuccessful 4
• Follow-up: Reassess within one month 4
• Recurrence counseling: 10-18% at 1 year, up to 36% long-term 4

Medications are NOT indicated for typical BPPV 4. The American Academy of Otolaryngology-Head and Neck Surgery recommends against routine neuroimaging or vestibular testing in diagnosed BPPV without red flags 2, 4.

Posttraumatic BPPV requires special consideration: Up to 67% require repeated treatments versus 14% for non-traumatic cases 1.

Vestibular Neuritis/Labyrinthitis

Acute phase treatment (first 48-72 hours):

Meclizine (FDA-approved for vertigo) 7:

• Dose: 25 mg to 100 mg daily in divided doses 7
• Administration: Swallow tablets whole 7
• Duration: Use only during acute phase; discontinue as soon as tolerated to avoid impeding vestibular compensation 8
• Warnings: May cause drowsiness; avoid alcohol and operating machinery 7
• Cautions: Use with care in asthma, glaucoma, or prostate enlargement due to anticholinergic effects 7

Vestibular rehabilitation therapy: Primary intervention after acute phase resolves, significantly improves gait stability compared to medication alone 4, 6. This is particularly beneficial for elderly patients, those with CNS disorders, or heightened fall risk 4.

Critical pitfall: Vestibular suppressants should be reduced or stopped in chronic dizziness, as they impede central vestibular compensation 8.

Ménière's Disease

First-line treatment 1, 4:

• Salt restriction: Dietary sodium limitation 1, 4
• Diuretics: Specific dosing not provided in guidelines but recommended 1, 4, 6

Refractory cases: Consider intratympanic dexamethasone or gentamicin 4, 5

Distinguishing features from vestibular migraine: Fluctuating hearing loss that worsens over time (versus stable/absent hearing loss in vestibular migraine), plus the classic triad of episodic vertigo lasting hours, tinnitus, and aural fullness 1, 2

Vestibular Migraine

Treatment approach 2, 4, 9:

• Acute/rescue therapy: Triptans, vestibular suppressants, and/or antiemetic agents 9
• Prophylaxis: Antiepileptics, beta-blockers, or antidepressants 9
• Lifestyle modifications: Identify and avoid triggers 4, 9

Diagnostic criteria: Migraine symptoms (photophobia, phonophobia, visual aura) during at least 50% of vertigo episodes 2. Episodes can be brief (<15 minutes) or prolonged (>24 hours) 2.

Vertebrobasilar Insufficiency (Central Cause)

This is a medical emergency requiring immediate neuroimaging and neurologic consultation 2, 3:

• Episode duration: Typically <30 minutes 1, 2
• Key distinguishing features: Gaze-evoked nystagmus, severe postural instability, nystagmus that does not fatigue or suppress with gaze fixation 1, 2
• Warning: Isolated transient vertigo may precede stroke by weeks or months 1, 2

Step 4: Identify Red Flags Requiring Urgent Evaluation

Immediate imaging (MRI brain without contrast preferred) 3, 4:

• Focal neurological deficits 3, 4
• Sudden hearing loss 3, 4
• Inability to stand or walk 3, 4
• Downbeating nystagmus or other central nystagmus patterns 2, 3, 4
• New severe headache with vertigo 2, 3
• Failure to respond to appropriate peripheral vertigo treatments 1, 2, 4
• High vascular risk patients with acute vestibular syndrome 3, 4

Step 5: Address Modifying Factors

The American Academy of Otolaryngology-Head and Neck Surgery recommends assessing for factors that modify management 1:

• Impaired mobility or balance: May require more intensive vestibular rehabilitation 1, 4
• CNS disorders: Posttraumatic BPPV is more refractory, requiring repeated treatments 1
• Medication review: Antihypertensives, sedatives, anticonvulsants, and psychotropic drugs are leading causes of chronic vestibular syndrome 3, 4
• Fall risk assessment: Particularly important in elderly patients 4

Common Pitfalls to Avoid

• Relying on CT instead of MRI: CT has only 20-40% sensitivity for posterior circulation infarcts versus MRI's significantly higher yield 3
• Assuming medications are needed for BPPV: Canalith repositioning is first-line; medications are unnecessary 4
• Prolonged use of vestibular suppressants: These impede central compensation and should be discontinued after the acute phase 8
• Missing concurrent diagnoses: BPPV can occur with Ménière's disease or vestibular neuritis 1
• Overlooking medication side effects: Mysoline, carbamazepine, phenytoin, antihypertensives, and cardiovascular medications commonly cause dizziness 1, 2
• Failing to distinguish cervical vertigo: Triggered by head rotation relative to body (not gravity), unlike BPPV 1
• Missing postural hypotension: Provoked by supine-to-upright position change, not positional changes relative to gravity 1