What is the treatment for dizziness in an adult patient with no known medical history?

Treatment of Dizziness in Adults

For an adult with dizziness and no known medical history, immediately perform the Dix-Hallpike maneuver at the bedside—if positive for BPPV (which accounts for the majority of cases), treat with the Epley maneuver immediately without any imaging or medications. 1

Initial Diagnostic Approach

The treatment of dizziness depends entirely on identifying the underlying cause through timing and triggers, not the patient's subjective description of symptoms 2:

Categorize by Timing Pattern

• Brief episodic vertigo (seconds to minutes) triggered by head position changes indicates BPPV—perform Dix-Hallpike test immediately 1, 2
• Acute persistent vertigo (days to weeks) with constant symptoms suggests vestibular neuritis, labyrinthitis, or posterior circulation stroke—perform HINTS examination if trained 2
• Spontaneous episodic vertigo without positional trigger suggests vestibular migraine (especially with headache, photophobia, phonophobia) or Ménière's disease (with hearing loss, tinnitus, aural fullness) 3
• Chronic dizziness (weeks to months) requires medication review first, then screen for anxiety/panic disorder, posttraumatic vertigo, or progressive neurologic symptoms 2

Treatment Algorithm by Diagnosis

For BPPV (Most Common Cause)

Perform the Epley maneuver immediately upon diagnosis—this achieves 80% success after 1-3 treatments and 90-98% success with repeat maneuvers if needed. 1

• The Epley maneuver involves: patient sitting upright with head turned 45° toward affected ear, rapidly laying back to supine head-hanging 20° position for 20-30 seconds, turning head 90° toward unaffected side, rolling patient onto shoulder while maintaining head position, then returning to upright 1
• Do NOT prescribe vestibular suppressant medications (meclizine, antihistamines, benzodiazepines) for BPPV—they have no evidence of effectiveness and cause drowsiness, cognitive deficits, increased fall risk, and interfere with central compensation 1
• Do NOT impose postprocedural restrictions after the Epley maneuver—patients can resume normal activities immediately 1
• Reassess within 1 month to confirm symptom resolution 1

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

• Diagnose with supine roll test showing geotropic or apogeotropic nystagmus 1
• Geotropic variant: Perform Barbecue Roll (Lempert) maneuver (50-100% success) or Gufoni maneuver (93% success) 1
• Apogeotropic variant: Perform Modified Gufoni maneuver (patient lies on affected side) 1

For Vestibular Neuritis/Labyrinthitis

• Initiate vestibular rehabilitation therapy as soon as possible 3
• Consider short-term vestibular suppressants ONLY for severe nausea/vomiting in the acute phase (first 24-48 hours), then discontinue 1

For Vestibular Migraine

• Initiate migraine prophylaxis and lifestyle modifications 2, 3
• Avoid vestibular suppressants which interfere with compensation 1

For Ménière's Disease

• Start salt restriction and diuretics 2
• Consider intratympanic treatments for refractory cases 2

For Chronic Dizziness

• First step: Review and discontinue/adjust medications (antihypertensives, sedatives, anticonvulsants, psychotropic drugs)—this is the most common reversible cause 2
• Screen for anxiety/panic disorder and treat with psychiatric care and cognitive behavioral therapy if present 2
• Refer for vestibular rehabilitation therapy if symptoms persist despite initial treatment—this significantly improves gait stability, particularly in elderly patients 1, 2

When Imaging Is Required

Do NOT order imaging for typical BPPV with positive Dix-Hallpike test and normal neurologic exam. 2

Red Flags Requiring Urgent MRI Brain (Without Contrast)

• Focal neurological deficits (dysarthria, diplopia, numbness, weakness) 2, 3
• Sudden unilateral hearing loss 2
• Inability to stand or walk 2
• Downbeating or other central nystagmus patterns 2
• New severe headache accompanying dizziness 2
• Progressive neurologic symptoms 2
• HINTS examination suggesting central cause (when performed by trained examiner) 2
• High vascular risk patients (age >50, hypertension, diabetes, prior stroke) with acute vestibular syndrome 2

Never use CT instead of MRI when stroke is suspected—CT has only 20-40% sensitivity for posterior circulation infarcts compared to MRI's superior detection. 2

Critical Pitfalls to Avoid

• Do not rely on patient descriptions of "spinning" versus "lightheadedness"—focus exclusively on timing and triggers 2, 3
• Do not assume normal neurologic exam excludes stroke—75-80% of posterior circulation strokes present with no focal neurologic deficits 2
• Do not prescribe meclizine or other vestibular suppressants for BPPV—they are ineffective as definitive treatment and cause significant adverse effects including increased fall risk 1
• Do not skip the Dix-Hallpike maneuver—it is the gold standard diagnostic test and takes less than 2 minutes 1, 3
• Do not order imaging for straightforward BPPV—this delays effective treatment unnecessarily 2, 3
• Do not forget to assess fall risk, especially in elderly patients—BPPV increases fall risk 12-fold 1

Special Considerations for Treatment Failures

If symptoms persist after initial Epley maneuver 1:

• Repeat Dix-Hallpike test to confirm persistent BPPV
• Perform additional repositioning maneuvers (achieves 90-98% success)
• Check for canal conversion (occurs in 6-7% of cases)
• Evaluate for multiple canal involvement or bilateral BPPV
• Consider coexisting vestibular pathology
• Rule out CNS disorders if atypical features present

Self-Treatment Option

Teach motivated patients self-administered Epley maneuver after at least one properly performed in-office treatment—this achieves 64% improvement compared to only 23% with Brandt-Daroff exercises. 1