What are the treatment options for vertigo?

Treatment Options for Vertigo

The first-line treatment for vertigo depends on the underlying cause, with particle repositioning maneuvers being the most effective treatment for benign paroxysmal positional vertigo (BPPV), while vestibular suppressant medications should not be used routinely for BPPV but may be appropriate for other causes of vertigo. 1

Diagnosis-Based Treatment Approach

1. Benign Paroxysmal Positional Vertigo (BPPV)

BPPV is the most common cause of vertigo and requires specific treatment:

• First-line treatment: Canalith Repositioning Procedures (CRP)

  • Posterior canal BPPV: Epley maneuver or Semont maneuver 1
  • Lateral canal BPPV: Roll maneuvers 1
  • Success rates of 90-98% with repeated maneuvers 1

• Medications: NOT recommended as primary treatment

  • Vestibular suppressants (antihistamines, benzodiazepines) should NOT be routinely used 1
  • May be used briefly for severe nausea/vomiting only 1

• Alternative options:

  • Vestibular rehabilitation exercises (either self-administered or clinician-guided) 1
  • Observation with follow-up (for mild cases) 1

2. Vestibular Neuritis/Labyrinthitis

• Acute phase treatment:

  • Vestibular suppressants for symptom control (short-term only)
  • Antiemetics for nausea/vomiting
  • Positioning (head and trunk raised 20°, lying on healthy side) 2

• Recovery phase:

  • Vestibular rehabilitation exercises to promote compensation
  • Gradual withdrawal of suppressant medications

3. Ménière's Disease

• Acute attacks:

  • Vestibular suppressants for vertigo control
  • Antiemetics for nausea/vomiting

• Prevention of attacks:

  • Low-salt diet and diuretics 3
  • Lifestyle modifications (avoiding triggers)
  • Regular follow-up to monitor hearing and vertigo control 1

4. Vestibular Migraine

• Acute treatment:

  • Antimigraine medications
  • Antiemetics
  • Vestibular suppressants

• Prevention:

  • Calcium channel antagonists
  • Tricyclic antidepressants
  • Beta-blockers 4
  • Dietary modifications

Pharmacological Options

Vestibular Suppressants

1. Antihistamines:

   • Meclizine (25-100mg daily in divided doses) - FDA approved for vertigo associated with vestibular system diseases 5
   • Diphenhydramine
   • Common side effects: drowsiness, dry mouth 5

2. Benzodiazepines:

   • Diazepam, clonazepam
   • Mechanism: potentiate GABA inhibitory effects
   • Caution: may impair central compensation, risk of dependence 1

3. Antiemetics:

   • Promethazine (phenothiazine with antihistamine properties)
   • Ondansetron (5-HT3 antagonist)
   • Metoclopramide 2

4. Anticholinergics:

   • Scopolamine - primarily for motion sickness
   • Caution in patients with glaucoma, prostatic hypertrophy, asthma 5

Important Considerations

Follow-up and Reassessment

• Reassess within 1 month after initial treatment to confirm symptom resolution 1
• Evaluate treatment failures for:
  • Persistent BPPV requiring additional maneuvers
  • Alternative or coexisting vestibular disorders
  • Possible CNS disorders masquerading as BPPV (3% of treatment failures) 1

Safety Concerns

• Medications causing drowsiness require caution with driving and operating machinery 5
• Vertigo increases fall risk, especially in elderly patients 1
• Patient education about safety precautions is essential 1

Common Pitfalls to Avoid

1. Overuse of vestibular suppressants: These medications may delay central compensation and should be used short-term 1

2. Missing central causes: Persistent symptoms despite appropriate treatment warrant neurological evaluation 1

3. Inadequate follow-up: Vertigo can recur and may require additional treatment 1

4. Treating symptoms without diagnosis: Different types of vertigo require different treatments; proper diagnosis is essential 1

5. Ignoring impact on quality of life: Vertigo can be severely disabling and affect mental health 6

By following this structured approach based on accurate diagnosis, most patients with vertigo can be effectively managed with significant improvement in symptoms and quality of life.