What is the appropriate treatment for vertigo?

Treatment of Vertigo

The treatment of vertigo depends critically on the underlying cause, but for the most common cause—benign paroxysmal positional vertigo (BPPV)—clinicians should perform canalith repositioning procedures (such as the Epley maneuver) rather than prescribing vestibular suppressant medications. 1

BPPV (85-95% of positional vertigo cases)

Primary Treatment:

• Perform canalith repositioning maneuvers (Epley maneuver for posterior canal BPPV, which accounts for 85-95% of BPPV cases) 1
• These procedures directly address the pathophysiology by repositioning displaced otoconia
• Success rates are high with immediate symptom resolution in many patients

What NOT to do:

• Do not routinely prescribe vestibular suppressants (antihistamines, benzodiazepines) for BPPV 1
• Do not order routine imaging (MRI/CT) in the absence of additional concerning signs 1
• Do not order vestibular function testing for straightforward BPPV 1

Alternative approaches:

• Observation with follow-up is acceptable for up to 1 week, as BPPV can spontaneously resolve in ~20% by 1 month and 50% by 3 months 1, 2
• Vestibular rehabilitation (self-administered or therapist-directed) may be offered 1
• Brandt-Daroff exercises for patient self-treatment 1

Ménière's Disease

Acute vertigo attacks:

• Offer a limited course of vestibular suppressants (antihistamines, benzodiazepines) for symptom control during acute attacks only 3
• These medications are for symptomatic relief, not cure
• Benzodiazepines carry significant dependence risk and should be used cautiously 3

Long-term management (stepwise approach):

1. First-line: Patient education on dietary/lifestyle modifications 3

   • Sodium restriction (reduces inner ear fluid)
   • Limit caffeine, alcohol, nicotine
   • Adequate hydration and sleep
   • Stress management

2. Second-line: Intratympanic steroids for active disease 3

3. Third-line: Intratympanic gentamicin for patients not responsive to nonablative therapy 3

4. Fourth-line: Vestibular rehabilitation/physical therapy for patients who failed less definitive therapy with nonusable hearing 3

5. Last resort: Surgical ablative therapy (reserved for refractory cases with nonusable hearing) 3

What NOT to do:

• Do not prescribe positive pressure therapy 3
• Do not routinely order vestibular function testing or electrocochleography for diagnosis 3

Vestibular Neuritis

• Vestibular suppressants for acute symptom relief (maximum 3 days) 4
• Vestibular rehabilitation is the primary treatment after initial symptom control 5, 4
• Early mobilization improves outcomes

Vestibular Migraine

• Acute: Antihistamines and benzodiazepines for symptom relief (triptans have uncertain efficacy) 6
• Prophylaxis: Lifestyle modifications, vestibular rehabilitation, oral migraine prophylactics, consider CGRP-targeted therapies 7, 6
• Treatment overlaps with persistent postural perceptual dizziness management 7

Critical Pitfalls to Avoid

Red flags requiring urgent evaluation (potential central causes):

• New focal neurological signs
• Severe headache
• Inability to walk
• Vertical or direction-changing nystagmus
• Normal head impulse test with acute vertigo (suggests central pathology)

Common mistakes:

• Prescribing vestibular suppressants for BPPV instead of performing repositioning maneuvers 1
• Using vestibular suppressants beyond 3 days for acute conditions 4
• Ordering unnecessary imaging and vestibular testing for straightforward peripheral vertigo 1, 3
• Failing to educate patients about natural history and self-management strategies 3

General Principles

Timing of vestibular suppressants:

• Use only for acute symptom control (maximum 3 days) 4
• Prolonged use impairs central compensation and delays recovery
• Never use as monotherapy for BPPV 1

Vestibular rehabilitation:

• Indicated for vestibular hypofunction, chronic symptoms, and after acute vestibular events 8, 5
• Can be self-administered or therapist-directed
• Promotes central compensation and improves balance

Patient education is mandatory for all vestibular disorders to improve outcomes, enable shared decision-making, and reduce unnecessary healthcare utilization 3