What is the treatment for an adult patient with dizziness and no known severe medical conditions?

Treatment for Dizziness in Adults

The treatment for dizziness depends entirely on the underlying cause, which must be identified through focused history and physical examination—most commonly, if benign paroxysmal positional vertigo (BPPV) is diagnosed via a positive Dix-Hallpike maneuver, perform canalith repositioning procedures (Epley maneuver) immediately, which has an 80% success rate after 1-3 treatments and 90-98% success with repeat maneuvers. 1

Initial Diagnostic Approach

The first critical step is categorizing dizziness by timing and triggers rather than relying on the patient's subjective description of "spinning" or "lightheadedness," which are unreliable. 2, 3

Key History Elements to Obtain:

• Duration of episodes: Seconds suggests BPPV, minutes to hours suggests vestibular migraine or Ménière's disease, days to weeks suggests vestibular neuritis or stroke 3
• Triggers: Positional changes (rolling over in bed, looking up, bending down) strongly suggest BPPV 1
• Associated symptoms: Hearing loss, tinnitus, or aural fullness suggest Ménière's disease; headache with photophobia/phonophobia suggests vestibular migraine 2, 3
• Vascular risk factors: Age >50, hypertension, diabetes, atrial fibrillation, or prior stroke increase stroke risk to 11-25% even with normal neurologic exam 3
• Medication review: Antihypertensives, sedatives, anticonvulsants, and psychotropic drugs are leading reversible causes 3

Essential Physical Examination:

• Dix-Hallpike maneuver for suspected BPPV: Positive test shows 5-20 second latency, torsional upbeating nystagmus toward the affected ear, symptoms resolving within 60 seconds 1, 2
• Supine roll test if Dix-Hallpike is negative but history suggests positional vertigo (tests lateral canal BPPV) 1
• Complete neurologic examination to identify focal deficits suggesting central pathology 2
• HINTS examination (Head Impulse, Nystagmus, Test of Skew) for acute persistent vertigo—has 100% sensitivity for stroke when performed by trained practitioners 2, 3

Treatment Based on Diagnosis

For BPPV (Most Common Cause):

Perform canalith repositioning procedures (Epley maneuver) immediately—this is first-line treatment with 80% success after 1-3 treatments. 1, 2

• Do NOT order imaging or vestibular testing if Dix-Hallpike is positive and no additional concerning features are present 1
• Do NOT prescribe vestibular suppressant medications (antihistamines, benzodiazepines) routinely—they are unnecessary for BPPV and impede central compensation 1, 4
• Do NOT recommend postprocedural postural restrictions after the Epley maneuver—they provide no benefit 1
• Reassess within 1 month to document resolution or persistence of symptoms 1

For Treatment Failures or Persistent Symptoms:

• Repeat Dix-Hallpike testing and perform additional repositioning maneuvers if still positive—success rate reaches 90-98% with repeat procedures 1, 2
• Refer for vestibular rehabilitation therapy if symptoms persist despite repositioning—particularly beneficial for elderly patients, those with CNS disorders, or heightened fall risk 1, 4, 2
• Evaluate for unresolved BPPV and/or underlying peripheral vestibular or central nervous system disorders 1

For Vestibular Neuritis:

• Vestibular suppressants (meclizine, antihistamines, benzodiazepines) may be used ONLY in the acute phase (first 2-3 days) for severe symptoms 4, 5
• Begin vestibular rehabilitation therapy as soon as acute symptoms subside (typically after first few days)—prolonged use of suppressants impedes central compensation 4
• Include habituation exercises, gaze stabilization, and balance training in rehabilitation 4

For Ménière's Disease:

• Salt restriction and diuretics are first-line management 3
• Intratympanic dexamethasone or gentamicin for refractory cases 6
• Obtain audiogram to document low-to-mid frequency sensorineural hearing loss 3

For Vestibular Migraine:

• Migraine prophylaxis and lifestyle modifications are essential 2, 3
• Vestibular migraine accounts for 14% of all vertigo cases but is extremely under-recognized 3

When Imaging IS Required

MRI brain without IV contrast is indicated for: 1, 2, 3

• Abnormal neurologic examination
• HINTS examination suggesting central cause
• High vascular risk patients with acute vestibular syndrome (even with normal neurologic exam)
• Unilateral or pulsatile tinnitus
• Asymmetric hearing loss
• Progressive neurologic symptoms
• Sudden hearing loss (urgent red flag)

Do NOT order CT head for isolated dizziness—it has <1% diagnostic yield and misses most posterior circulation infarcts. 1, 2, 3

Critical Red Flags Requiring Urgent Evaluation

• Focal neurological deficits 3
• Sudden hearing loss 3
• Inability to stand or walk 3
• New severe headache accompanying dizziness 2, 3
• Downbeating nystagmus or other central nystagmus patterns 3
• Failure to respond to appropriate vestibular treatments 3

Common Pitfalls to Avoid

• Do not rely on patient descriptions of "spinning" versus "lightheadedness"—focus on timing and triggers instead 2, 3
• Do not assume normal neurologic exam excludes stroke—75-80% of patients with posterior circulation infarct have no focal deficits 3
• Do not use vestibular suppressants as long-term treatment—they delay compensation and have significant side effects 4
• Do not order routine imaging for typical BPPV—it wastes resources and delays effective treatment 1
• Do not overlook medication side effects—they are a leading reversible cause of chronic dizziness 3

Special Considerations for Elderly Patients

• BPPV is present in 9% of elderly patients referred for geriatric evaluation—three-fourths had fallen within prior 3 months 3
• Dizziness increases fall risk 12-fold in elderly patients 3
• Implement fall prevention strategies immediately and consider home safety assessment 4, 3
• Consider vestibular rehabilitation therapy early—particularly beneficial for elderly patients with impaired mobility or balance 1, 4