What are the treatment options for positional vertigo?

From the Guidelines

The most effective treatment for positional vertigo, also known as benign paroxysmal positional vertigo (BPPV), is the Epley maneuver, which involves a series of head movements that help reposition the displaced calcium crystals in the inner ear. This can be performed by a healthcare provider or taught to patients for home use 1. The Semont maneuver and Brandt-Daroff exercises are alternative positioning techniques that may also be effective.

Key Points to Consider

• For symptomatic relief during vertigo episodes, medications such as meclizine (25mg every 4-6 hours as needed), dimenhydrinate (50mg every 4-6 hours), or promethazine (25mg every 6 hours) can help reduce dizziness and nausea, though these don't treat the underlying cause.
• Most cases of BPPV resolve within a few weeks with proper treatment, but recurrence is common (about 30% of patients) 1.
• If symptoms persist despite repositioning maneuvers, vestibular rehabilitation therapy may be recommended to help the brain compensate for balance problems.
• Surgery is rarely needed but may be considered in severe, persistent cases.
• BPPV occurs when calcium carbonate crystals become dislodged from their normal location in the inner ear and move into the semicircular canals, causing abnormal fluid movement that confuses the brain about head position, resulting in vertigo.

Diagnosis and Treatment Approach

• Diagnosis of BPPV is primarily through the Dix-Hallpike maneuver and supine roll test, with the clinician assessing for torsional, upbeating nystagmus and horizontal or no nystagmus, respectively 1.
• The Epley maneuver is recommended as the initial therapy for patients with posterior canal BPPV, with a strong recommendation against postprocedural postural restrictions after the procedure.
• Vestibular rehabilitation and observation with follow-up are considered options for the treatment of BPPV, while medical therapy with vestibular suppressant medications is not routinely recommended.

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 option for positional 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 adverse reactions, such as anaphylactic reaction, dry mouth, headache, fatigue, and vomiting, when prescribing meclizine hydrochloride tablets.

From the Research

Treatment Options for Positional Vertigo

The treatment options for positional vertigo, also known as benign paroxysmal positional vertigo (BPPV), include various physical maneuvers and exercises. Some of the most effective treatments are:

• The Epley maneuver, also known as the canalith repositioning maneuver, which has been shown to be effective in resolving vertigo symptoms in patients with posterior canal BPPV 3
• The Semont maneuver, which is another type of particle repositioning maneuver that has been shown to be effective in treating BPPV 4, 5
• Vestibular rehabilitation exercises, which can be effective in treating BPPV, especially when combined with other treatments such as the Semont maneuver 5
• The Brandt-Daroff exercise, which is a type of vestibular rehabilitation exercise that can be effective in treating BPPV 4

Effectiveness of Treatment Options

The effectiveness of these treatment options has been studied in various clinical trials. For example:

• A study published in 2014 found that the Epley maneuver was effective in resolving vertigo symptoms in 56% of patients with posterior canal BPPV, compared to 21% of patients who received a sham maneuver 3
• A study published in 2005 found that the Semont maneuver, the Epley maneuver, and the Brandt-Daroff exercise were all effective in reducing vertigo symptoms in patients with BPPV, although the Semont maneuver and the Epley maneuver were more effective than the Brandt-Daroff exercise 4
• A study published in 2000 found that the combination of the Semont maneuver and vestibular rehabilitation exercises was effective in resolving vertigo symptoms in 100% of patients with BPPV at three months of follow-up 5

Considerations for Patients with Cervical Spine Problems

For patients with cervical spine problems, such as spondylosis or disc prolapse, the Epley maneuver may be contraindicated due to the risk of cervical spine fracture. In these cases, alternative treatments such as a new particle repositioning maneuver may be effective and safer 6