What is the treatment for vertigo (benign paroxysmal positional vertigo)?

From the Guidelines

To treat vertigo, start with identifying the underlying cause while managing symptoms, and for benign paroxysmal positional vertigo (BPPV), perform the Epley maneuver or modified Epley (half-somersault) at home to reposition inner ear crystals, as recommended by the American Academy of Otolaryngology-Head and Neck Surgery 1.

Key Considerations

• The Epley maneuver is a effective treatment for BPPV, with a success rate of 78.6%-93.3% improvement in symptoms 1.
• Vestibular suppressant medications, such as antihistamines and benzodiazepines, are not recommended for routine treatment of BPPV, except for short-term management of autonomic symptoms like nausea or vomiting in severely symptomatic patients 1.
• Vestibular rehabilitation exercises may be offered to patients with BPPV to help the brain compensate for balance issues, based on controlled observational studies and a balance of benefit and harm 1.

Treatment Approach

• Identify the underlying cause of vertigo and manage symptoms accordingly.
• For BPPV, perform the Epley maneuver or modified Epley (half-somersault) at home to reposition inner ear crystals.
• For symptomatic relief, consider over-the-counter antihistamines like meclizine (Antivert) 25mg every 4-6 hours or dimenhydrinate (Dramamine) 50mg every 4-6 hours as needed for dizziness, but use with caution and only for short-term management of autonomic symptoms.
• Prescription options, such as scopolamine patches or benzodiazepines, should be used with caution and only for severe cases.
• Stay hydrated and avoid sudden head movements during episodes.
• For Ménière's disease-related vertigo, reduce salt intake to less than 2g daily and consider diuretics like hydrochlorothiazide 25mg daily.
• If vertigo is accompanied by hearing loss, facial weakness, severe headache, or persists beyond a few days, seek immediate medical attention as these may indicate more serious conditions requiring different treatment approaches.

From the FDA Drug Label

Meclizine hydrochloride tablets are indicated for the treatment of vertigo associated with diseases affecting the vestibular system in adults (1). Recommended dosage: 25 mg to 100 mg daily, in divided doses (2.1).

Treatment for Vertigo: Meclizine hydrochloride tablets are indicated for the treatment of vertigo associated with diseases affecting the vestibular system in adults.

• The recommended dosage is 25 mg to 100 mg daily, in divided doses 2.
• Key Considerations: Use with caution when driving a car or operating dangerous machinery due to potential drowsiness, and prescribe with care to patients with a history of asthma, glaucoma, or enlargement of the prostate gland 2.

From the Research

Treatment Options for Vertigo

• The treatment of vertigo depends on the underlying cause, with different approaches for otological, central, psychogenic, and undetermined causes 3.
• For otological vertigo, vestibular suppressants such as anticholinergics and benzodiazepines are used, while salt restriction and diuretics are used in Ménière's disease 3.
• Central vertigo is treated with prophylactic agents such as L-channel calcium channel antagonists, tricyclic antidepressants, and beta-blockers, especially in cases of migraine-associated vertigo 3.
• Psychogenic vertigo is often treated with benzodiazepines, and an eclectic approach incorporating trials of vestibular suppressants and physical therapy is recommended for individuals with stroke or other structural lesions of the brainstem or cerebellum 3.

Epley Maneuver for Benign Paroxysmal Positional Vertigo (BPPV)

• The Epley maneuver 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 test 4, 5, 6.
• Meta-analyses have shown that the Epley maneuver is associated with higher complete resolution of vertigo and conversion to a negative Dix-Hallpike test compared to control groups 5, 6.
• The Epley maneuver has been compared to other particle repositioning maneuvers, such as the Semont and Gans maneuvers, and has been found to be comparable in efficacy 6.

Diagnosis and Approach to Vertigo

• A systematic approach to diagnosing the cause of vertigo is essential, with categorization of dizziness into one of four groups: lightheadedness, pre-syncope, disequilibrium, and vertigo 7.
• Central vertigo must be differentiated from peripheral vertigo, and the tempo of vertiginous attacks and associated symptoms can help differentiate between causes of peripheral vertigo, such as benign paroxysmal positional vertigo, Ménière's disease, and vestibular neuronitis 7.