What are the instructions for a patient (pt) with vertigo?

From the Guidelines

For patients with vertigo, I recommend a combination of medication, lifestyle modifications, and vestibular rehabilitation exercises, prioritizing the Epley maneuver for Benign Paroxysmal Positional Vertigo (BPPV) as the most effective treatment option, as supported by the 2017 clinical practice guideline update 1. When managing vertigo, it's essential to consider the underlying cause, and for BPPV, the Epley maneuver has been shown to be highly effective in resolving symptoms.

• The Epley maneuver involves a series of head position changes designed to move free-floating particles in the inner ear back into the vestibule, relieving the pathologic stimulus that causes vertigo.
• According to the 2017 guideline update, the Epley maneuver is more effective than sham maneuvers or controls in resolving vertigo symptoms, with a significant improvement in symptoms and a higher likelihood of converting to a negative Dix-Hallpike maneuver 1. In addition to the Epley maneuver, patients with vertigo may benefit from:
• Vestibular suppressants like meclizine (Antivert) 25mg every 6-8 hours as needed for acute symptoms, or diazepam 2-5mg every 8 hours for severe cases, to reduce the intensity of vertigo by suppressing vestibular signals in the brain.
• Lifestyle modifications, such as moving slowly when changing positions, avoiding sudden head movements, staying hydrated, and limiting caffeine, alcohol, and salt intake, which can worsen symptoms.
• Gaze stabilization exercises, which help the brain adapt to vestibular dysfunction. It's crucial to note that if symptoms persist beyond 1-2 weeks or are accompanied by hearing loss, severe headache, or neurological symptoms, patients should seek immediate medical attention, as these could indicate more serious conditions requiring different treatment, such as Meniere's disease, which is characterized by episodic vertigo, fluctuating hearing loss, tinnitus, and aural fullness 1.

From the FDA Drug Label

MECLIZINE HYDROCHLORIDE tablets, for oral use Initial U. S. Approval: 1957 INDICATIONS AND USAGE Meclizine hydrochloride tablets are indicated for the treatment of vertigo associated with diseases affecting the vestibular system in adults (1). DOSAGE AND ADMINISTRATION Recommended dosage: 25 mg to 100 mg daily, in divided doses (2.1). Tablets: Swallow whole (2.2).

To give a patient meclizine for vertigo, the recommended dosage is 25 mg to 100 mg daily, in divided doses 2. The patient should swallow the tablets whole.

• Key points:
  • Dosage: 25 mg to 100 mg daily
  • Administration: divided doses, swallow whole
• Important consideration: use with caution when driving a car or operating dangerous machinery due to potential drowsiness.

From the Research

Instructions for Performing the Epley Manoeuvre

To provide treatment for vertigo, specifically for benign paroxysmal positional vertigo (BPPV), the Epley manoeuvre is a recommended approach 3, 4, 5, 6. The steps involved in the Epley manoeuvre are designed to help relocate the calcium particles (otoconia) in the inner ear that cause the vertigo.

Key Points to Consider

• The Epley manoeuvre is a safe and effective treatment for posterior canal BPPV, with a significant reduction in vertigo symptoms and conversion of a positive Dix-Hallpike test to a negative one 5, 6.
• The manoeuvre involves a series of specific head and body movements, which should be performed by a trained healthcare professional 3, 4.
• The treatment has been shown to have a high success rate, with complete resolution of vertigo symptoms in a significant proportion of patients 5, 6.
• There is no good evidence that the Epley manoeuvre provides a long-term resolution of symptoms, and recurrence rates can be high 4, 5.

Performing the Epley Manoeuvre

The Epley manoeuvre typically involves the following steps:

• The patient sits on an examination table with their legs extended.
• The healthcare professional turns the patient's head to the right (or left, depending on the affected ear) and has them lie down on their back.
• The healthcare professional then rolls the patient onto their side, with their head still turned, and holds them in this position for about 30 seconds.
• The patient is then rolled onto their other side, with their head still turned, and held in this position for another 30 seconds.
• The patient is then helped to sit up and the process is repeated on the other side.

Important Considerations

• The Epley manoeuvre should only be performed by a trained healthcare professional, as improper technique can lead to further injury or worsening of symptoms 3, 4.
• Patients with certain medical conditions, such as neck or back problems, may need to modify the manoeuvre or avoid it altogether 5.
• The Epley manoeuvre is not a cure for BPPV, and patients may need to repeat the treatment if symptoms recur 4, 5.