From the Guidelines
Vertigo in ENT practice is best managed with a combination of medications and vestibular rehabilitation, prioritizing the underlying cause and focusing on reducing morbidity, mortality, and improving quality of life. For acute vertigo, start with vestibular suppressants like dimenhydrinate 50mg every 6 hours or meclizine 25mg every 8 hours for 3-5 days maximum to control symptoms, as recommended by the most recent guidelines 1. It is crucial to differentiate between various causes of vertigo, including benign paroxysmal positional vertigo (BPPV), Ménière's disease, vestibular neuritis, and others, to provide targeted treatment.
Key Considerations
- For BPPV specifically, the Epley maneuver should be performed promptly, as it has a high success rate in repositioning displaced otoconia 1.
- Patients with Ménière's disease may benefit from a low-salt diet (less than 2g sodium daily) and diuretics like hydrochlorothiazide 25mg daily, as suggested by recent clinical practice guidelines 1.
- For vestibular neuritis, a short course of methylprednisolone starting at 100mg daily and tapering over 10-14 days can help reduce inflammation, based on the latest evidence 1.
- Long-term management should focus on vestibular rehabilitation exercises to promote central compensation, which is supported by high-quality studies 1.
Treatment Approaches
- Vestibular suppressants should be limited to short-term use as they can delay compensation mechanisms, emphasizing the need for a balanced approach that considers both symptom control and long-term recovery 1.
- Patients should be advised to avoid sudden head movements during acute episodes and to sit or lie down when vertigo occurs to prevent falls, highlighting the importance of patient education in managing vertigo effectively.
- Antihistamines like betahistine 16mg three times daily may help some patients with recurrent vertigo, offering an additional therapeutic option for selected cases 1.
By prioritizing the most recent and highest quality evidence, such as the 2020 clinical practice guideline on Ménière's disease 1, and considering the principles of reducing morbidity, mortality, and improving quality of life, clinicians can provide effective and personalized care for patients with vertigo.
From the Research
Causes of Vertigo
- Benign paroxysmal positional vertigo, acute vestibular neuronitis, and Meniere's disease are the most common causes of vertigo 2
- Other causes of vertigo include cerebrovascular disease, migraine, psychological disease, perilymphatic fistulas, multiple sclerosis, and intracranial neoplasms 2
- Otological causes are the most common, followed by central, somatosensory, and visual causes 3
Diagnosis of Vertigo
- A detailed patient history is essential in determining the cause of vertigo 4
- The Dix-Hallpike maneuver and supine roll test can be used to diagnose benign paroxysmal positional vertigo (BPPV) 5
- A stepwise algorithmic approach can be used to determine whether the cause is central or peripheral in origin 4
- Bedside assessment of vertigo can help differentiate between central and peripheral causes 6
Clinical Presentations
- Peripheral vertigo is typically characterized by sudden, brief episodes of vertigo precipitated by specific head movements 5
- Central vertigo often presents with associated neurologic signs and symptoms, such as nystagmus that does not lessen when the patient focuses 2
- The tempo of the vertiginous attacks and other associated symptoms can help differentiate between different causes of peripheral vertigo 3