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

From the Guidelines

Treatment for recurrent vertigo should prioritize the use of canalith repositioning procedures, such as the Epley maneuver, as initial therapy for patients with posterior canal Benign Paroxysmal Positional Vertigo (BPPV) 1. This approach is based on the strongest and most recent evidence, which recommends canalith repositioning procedures as the initial treatment for posterior canal BPPV due to their high efficacy and low risk of adverse effects.

Key Considerations

• The diagnosis of BPPV should be made based on the patient's history and physical examination, including the Dix-Hallpike maneuver 1.
• Clinicians should assess patients with BPPV for factors that modify management, including impaired mobility or balance, central nervous system disorders, a lack of home support, and/or increased risk for falling 1.
• Vestibular rehabilitation may be offered as an option for the treatment of BPPV, either self-administered or with a clinician 1.
• Clinicians should not routinely treat BPPV with vestibular suppressant medications such as antihistamines and/or benzodiazepines 1.

Lifestyle Modifications

• Patients with recurrent vertigo should be advised to avoid sudden head movements, sit or lie down immediately when feeling dizzy, stay hydrated, limit salt, caffeine, and alcohol intake, and manage stress.
• Underlying causes such as Meniere's disease, vestibular migraine, or vestibular neuritis may require specific treatments, and clinicians should differentiate BPPV from other causes of imbalance, dizziness, and vertigo 1.

Follow-up and Education

• Clinicians should reassess patients within 1 month after an initial period of observation or treatment to document resolution or persistence of symptoms 1.
• Patients should be educated regarding the impact of BPPV on their safety, the potential for disease recurrence, and the importance of follow-up 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).

The treatment for recurrent vertigo is meclizine hydrochloride tablets, with a recommended dosage of 25 mg to 100 mg daily, in divided doses 2.

• The dosage can be adjusted based on the patient's response.
• Tablets should be swallowed whole.
• It is essential to consider the potential for drowsiness and anticholinergic action when prescribing meclizine hydrochloride tablets.

From the Research

Treatment Options for Recurrent Vertigo

• The Epley maneuver, also known as the canalith repositioning procedure, is a safe and effective treatment for benign paroxysmal positional vertigo (BPPV) 3, 4, 5, 6.
• This procedure involves a series of movements that help to relocate the calcium particles in the inner ear, which can cause vertigo 4, 5, 6.
• The Epley maneuver has been shown to be effective in resolving vertigo symptoms and converting a positive Dix-Hallpike test to a negative test 4, 5, 6.
• Other treatment options for recurrent vertigo include vestibular suppressant medications and vestibular rehabilitation 3.
• For patients with Meniere's disease, treatment may include salt restriction and diuretics 3.
• In some cases, the Epley maneuver may be used to treat BPPV associated with Meniere's disease, with a high success rate in eliminating positional vertigo and nystagmus 7.

Efficacy of the Epley Maneuver

• Studies have consistently shown that the Epley maneuver is an effective treatment for BPPV, with a significant reduction in vertigo symptoms and a high rate of conversion from a positive to negative Dix-Hallpike test 4, 5, 6.
• The Epley maneuver has been compared to other treatment options, including sham maneuvers and other particle repositioning maneuvers, and has been shown to be superior in terms of efficacy and safety 6.
• However, the recurrence rate of BPPV after treatment with the Epley maneuver is relatively high, with one study reporting a recurrence rate of 36% 6.

Safety and Adverse Effects

• The Epley maneuver is generally considered to be a safe procedure, with few adverse effects reported 4, 5, 6.
• The most common adverse effect is nausea, which occurs in a small percentage of patients 6.
• Some patients may not be able to tolerate the Epley maneuver due to cervical spine problems or other medical conditions 6.