What is the recommended management plan for dizziness and vertigo following a head injury with chronic gliosis on brain MRI?

From the Guidelines

Management of post-traumatic dizziness and vertigo with chronic gliosis on MRI requires a multidisciplinary approach, with a focus on vestibular rehabilitation therapy (VRT) and active management of symptoms, as recommended by the most recent guidelines 1.

Key Components of Management

• Initial treatment should focus on VRT, which includes customized exercises to improve balance, reduce dizziness, and help the brain compensate for vestibular dysfunction.
• Medications may include betahistine (16-24 mg three times daily) to improve vestibular blood flow, or short-term use of vestibular suppressants like meclizine (25 mg every 4-6 hours as needed) for acute symptoms.
• For associated anxiety, SSRIs like sertraline (starting at 25-50 mg daily) may help.
• Patients should avoid triggers that worsen symptoms and maintain good sleep hygiene.

Importance of Regular Follow-up

Regular follow-up with a neurologist is essential to monitor the gliosis and adjust treatment. The chronic gliosis represents scarring from the head injury and may be contributing to symptoms by affecting brain regions involved in balance and spatial orientation.

Additional Considerations

If symptoms persist despite these measures, additional imaging or referral to specialized vestibular disorders clinics may be warranted. Patients should understand that recovery may be gradual, with improvement typically occurring over weeks to months with consistent therapy. A personalized management and rehabilitation plan, including a person-centered approach and shared decision-making, is also crucial 1.

From the FDA Drug Label

Meclizine hydrochloride tablets are indicated for the treatment of vertigo associated with diseases affecting the vestibular system in adults. The recommended management plan for dizziness and vertigo following a head injury with chronic gliosis on brain MRI may include meclizine for the treatment of vertigo, as it is indicated for the treatment of vertigo associated with diseases affecting the vestibular system in adults 2, 2.

• Key considerations: The presence of chronic gliosis on brain MRI suggests a possible underlying condition that may be contributing to the symptoms of dizziness and vertigo.
• Management approach: Treatment with meclizine may be considered to help manage vertigo symptoms.

From the Research

Management Plan for Dizziness and Vertigo

The recommended management plan for dizziness and vertigo following a head injury with chronic gliosis on brain MRI includes:

• Vestibular rehabilitation therapy (VRT) to address dysfunctional inner ear structures and improve perceived disability associated with dizziness postconcussion 3
• A thorough history and physical exam to diagnose mild traumatic brain injury (mTBI) and identify symptoms such as dizziness, hearing problems, headaches, cognitive, and sleep disturbances 4
• Specialized vestibular function tests, such as oculomotor and vestibular tasks, to sensitively and specifically identify individuals with acute mTBI 4
• Vestibular therapy and rehabilitation to improve cognitive function, ability to return to activities of daily living, and ability to return to work 4

Treatment Options

Treatment options for dizziness and vertigo after head trauma may include:

• Pharmacological treatment with anticholinergics, antihistamines, benzodiazepines, calcium channel antagonists, and dopamine receptor antagonists to modify the intensity of symptoms or affect the underlying disease process 5
• Vestibular suppressants, such as anticholinergics and benzodiazepines, for otological vertigo disorders such as Ménière's disease and vestibular neuritis 5
• Prophylactic agents, such as L-channel calcium channel antagonists, tricyclic antidepressants, and beta-blockers, for migraine-associated vertigo 5
• Physical therapy treatment for benign paroxysmal positional vertigo (BPPV) and bilateral vestibular paresis 5

Chronic Vestibular Dysfunction

Chronic vestibular dysfunction in traumatic head injury (THI) patients may relate to:

• The presence of multiple vestibular diagnoses, increasing the risk of 'missed' vestibular diagnoses leading to persisting symptoms 6
• The impact of brain trauma, which may impair brain plasticity mediated repair mechanisms 6
• The need for a comprehensive clinical and vestibular laboratory testing to identify individual patients' unique vestibular diagnoses and develop an effective treatment plan 6