What are the recommended treatments for vertigo?

Treatment of Vertigo

For benign paroxysmal positional vertigo (BPPV)—the most common cause of vertigo—perform the canalith repositioning procedure (Epley maneuver) immediately, which has an 80% success rate with 1-3 treatments and should NOT be followed by postural restrictions. 1

Algorithmic Approach by Vertigo Type

BPPV (85-95% of vertigo cases)

Diagnosis:

• Perform Dix-Hallpike maneuver: bring patient from upright to supine with head turned 45° to one side, neck extended 20°, affected ear down
• Positive test shows torsional, upbeating nystagmus 1

Treatment:

• Primary treatment: Canalith repositioning procedure (CRP/Epley maneuver) - STRONG recommendation 1
• Do NOT prescribe vestibular suppressants (antihistamines, benzodiazepines) routinely - STRONG recommendation against 1
• Do NOT impose postural restrictions after the procedure - STRONG recommendation against 1
• Alternative option: Observation with follow-up for 1 week if patient prefers, as BPPV is self-limited 2
• May offer vestibular rehabilitation (self-administered or therapist-directed) 1

Post-procedure expectations:

• Brief distress during treatment is normal
• Mild motion sensitivity may persist for hours to weeks 1
• Recurrence prevention: Consider vitamin D/calcium supplementation if serum vitamin D is low 2

Ménière's Disease

Acute vertigo attacks:

• Offer limited course of vestibular suppressants for symptom control 3
• May offer intratympanic steroids for active disease 3

Refractory disease:

• Offer intratympanic gentamicin for patients not responsive to nonablative therapy 3
• Offer vestibular rehabilitation/physical therapy for patients who failed less definitive therapy with nonusable hearing 3

Maintenance:

• Salt restriction and diuretics 4
• Do NOT prescribe positive pressure therapy - STRONG recommendation against 3

Vestibular Neuritis

• Vestibular suppressant medications for acute symptom relief (maximum 3 days) 5
• Vestibular rehabilitation 4

Vestibular Migraine

• Acute: Antihistamines and benzodiazepines for quick symptom relief 6
• Preventive: Lifestyle modifications, vestibular rehabilitation, oral migraine prophylactics, consider CGRP-targeted therapies 6
• Note: Triptan efficacy remains uncertain 6

Critical Pitfalls to Avoid

Do NOT routinely order:

• MRI/CT imaging for typical BPPV without additional concerning signs 1
• Vestibular function testing or electrocochleography for straightforward cases 3, 1
• Laboratory testing for uncomplicated vertigo 4

Medication cautions:

• Limit vestibular suppressants to maximum 3 days for acute symptoms 5
• Prolonged use prevents central compensation and delays recovery
• These medications are for symptom reduction, not cure 7

When to Escalate

Refer for surgical intervention when:

• BPPV is intractable despite multiple CRP attempts: consider canal-plugging surgery 2
• Ménière's disease with nonusable hearing fails all medical therapy: offer surgical ablative therapy 3

Red flags requiring urgent evaluation:

• New neurologic signs suggesting central cause
• Acute vestibular syndrome with central features on HINTS examination
• Nonfluctuating sensorineural hearing loss, tinnitus, or pressure not explained by peripheral disorder 3

The evidence strongly supports mechanical repositioning over medication for BPPV, which represents the vast majority of vertigo presentations. The 2017 AAO-HNS guidelines 1 provide the highest quality recommendations with strong evidence from multiple randomized controlled trials demonstrating superiority of the CRP approach.