What are the treatment options for a patient with ongoing dizziness?

Treatment for Ongoing Dizziness

For patients with persistent dizziness after initial evaluation, the treatment approach depends critically on the underlying diagnosis: perform canalith repositioning procedures (Epley maneuver) for confirmed BPPV with 90-98% success rates after repeat maneuvers, initiate vestibular rehabilitation therapy for persistent symptoms that fail initial treatment or have concurrent balance dysfunction, and address specific etiologies such as medication side effects, vestibular migraine, or Ménière's disease with targeted interventions. 1, 2

Algorithmic Approach to Treatment

Step 1: Reevaluate Treatment Failures

• Patients with persistent symptoms after initial therapy are classified as treatment failures and require systematic reevaluation to identify: (1) persistent BPPV responsive to additional maneuvers, (2) coexisting vestibular conditions, or (3) serious CNS disorders that may simulate BPPV. 1

• Obtain a focused history asking specifically if vertigo is provoked by positional changes relative to gravity (lying down, rolling over, bending down, tilting head back), which suggests persistent BPPV. 1

• Repeat the Dix-Hallpike test to confirm persistent BPPV before proceeding with additional treatment. 1

Step 2: Treatment Based on Diagnosis

For Confirmed Persistent BPPV:

• Perform repeat canalith repositioning procedures (CRP) as the treatment of choice, with success rates reaching 90-98% when additional repositioning maneuvers are performed. 1, 2

• Initial CRP failure rates range from 8-50%, making repeat maneuvers essential for treatment failures. 1

• For cases refractory to multiple CRP attempts, surgical plugging of the involved posterior semicircular canal or singular neurectomy has >96% success rates, though data quality limits definitive recommendations. 1

For Persistent Dizziness Without Confirmed BPPV:

• Vestibular rehabilitation therapy (VRT) is the primary intervention for persistent dizziness that has failed initial treatment, significantly improving gait stability compared to medication alone. 2

• VRT is particularly beneficial for elderly patients, those with CNS disorders, or patients with heightened fall risk. 2

• VRT includes habituation exercises, gaze stabilization, balance retraining, and fall prevention strategies. 2

Step 3: Address Specific Etiologies

Medication-Induced Dizziness:

• Review and modify medications, as medication side effects are a leading reversible cause of chronic vestibular syndrome. 2

• Focus on antihypertensives, sedatives, anticonvulsants, and psychotropic drugs. 2

Vestibular Migraine:

• Treat with migraine prophylaxis and lifestyle modifications when diagnostic criteria are met (episodic vestibular symptoms with migraine features during at least two episodes). 2

Ménière's Disease:

• Manage with salt restriction, diuretics, and in refractory cases, intratympanic treatments. 2, 3

Anxiety/Panic Disorder:

• Treat with psychiatric intervention and cognitive behavioral therapy when psychiatric symptoms are identified. 2

Step 4: Identify Red Flags Requiring Urgent Evaluation

• Focal neurological deficits, sudden hearing loss, inability to stand or walk, downbeating nystagmus, or failure to respond to appropriate vestibular treatments mandate urgent evaluation with neuroimaging (MRI brain without contrast preferred). 2

• New severe headache requires immediate imaging and neurologic consultation. 2

Pharmacologic Considerations

• Meclizine is FDA-approved for treatment of vertigo associated with vestibular system diseases in adults, though it should be used judiciously. 4

• Pharmacologic intervention is limited because medications often impair the central nervous system's ability to compensate for dizziness, making vestibular rehabilitation more effective long-term. 5

• Vestibular suppressants may provide temporary symptom relief but should not replace definitive treatment. 3

Critical Pitfalls to Avoid

• Do not assume treatment failure means the diagnosis was wrong—persistent BPPV is common and responds to repeat maneuvers. 1

• Do not rely solely on medications for ongoing dizziness—vestibular rehabilitation provides superior long-term outcomes. 2, 5

• Do not miss coexisting vestibular conditions that may require concurrent treatment beyond BPPV management. 1

• Do not delay reevaluation of treatment failures—early identification of persistent disease or alternative diagnoses prevents secondary complications. 1

• Avoid ordering neuroimaging for straightforward BPPV with positive Dix-Hallpike and no red flags, as it has extremely low diagnostic yield and delays appropriate treatment. 2

Follow-Up Strategy

• Reassess patients within one month after initial treatment to document resolution or persistence of symptoms. 2

• Counsel patients about recurrence risk (BPPV recurs in significant numbers), fall risk, and the importance of returning promptly if symptoms recur for repeat repositioning procedures. 2

• For elderly or frail patients, consider home safety assessment and supervision until symptoms resolve. 2