What are the treatment options for vertigo?

Treatment Options for Vertigo

Vertigo treatment should be tailored to the underlying cause, with particle repositioning maneuvers (PRMs) being the first-line treatment for benign paroxysmal positional vertigo (BPPV), the most common cause of vertigo. For BPPV, canalith repositioning procedures (CRPs) are the treatment of choice with success rates of 90-98% when additional maneuvers are performed as needed, rather than medication. 1

Diagnosis and Classification

Before treatment, proper diagnosis is essential:

• BPPV: Diagnosed when vertigo with nystagmus is provoked by the Dix-Hallpike maneuver (for posterior canal) or supine roll test (for lateral canal) 1
• Ménière's Disease: Characterized by episodic vertigo lasting 20 minutes to 12 hours with fluctuating hearing loss, tinnitus, and aural fullness 1
• Vestibular Neuritis/Labyrinthitis: Acute onset vertigo with nausea/vomiting
• Central Vertigo: Associated with neurological symptoms (e.g., migraine-associated vertigo)

Treatment Algorithm by Cause

1. BPPV Treatment

• First-line: Canalith Repositioning Procedures (CRPs)
  • Posterior canal: Epley or Semont maneuver
  • Lateral canal: Roll maneuvers (Lempert)
  • Success rates: 90-98% with repeated maneuvers 1
• Alternative: Vestibular rehabilitation exercises (self-administered or clinician-guided) 1
• Observation: May be offered with assured follow-up 1
• Medications: NOT recommended as primary treatment 1
• Follow-up: Reassessment within 1 month to confirm resolution 1

2. Vestibular Neuritis/Labyrinthitis

• Acute phase: Brief use of vestibular suppressants
  • Meclizine 25-100mg daily in divided doses 2, 3
  • Diazepam for severe symptoms (short-term use only) 3
• Recovery phase: Vestibular rehabilitation exercises
• Positioning: Patient should lie on healthy side with head/trunk raised 20° 4

3. Ménière's Disease

• Dietary modifications: Low-salt diet
• Medications: Diuretics
• Acute attacks: Vestibular suppressants (meclizine, diazepam) 1, 3
• Severe cases: Consider surgical options when medical management fails

4. Migraine-Associated Vertigo

• Prophylactic medications:
  • Calcium channel antagonists
  • Tricyclic antidepressants
  • Beta-blockers 3, 5
• Lifestyle modifications: Dietary triggers identification and avoidance

Pharmacological Options

• Meclizine (Antihistamine): 25-100mg daily in divided doses; indicated for vertigo associated with vestibular system diseases 2

  • Side effects: Drowsiness, dry mouth, blurred vision
  • Contraindicated in patients with glaucoma, prostatic hypertrophy, asthma

• Benzodiazepines: For severe, acute vertigo or anxiety-related vertigo

  • Use only short-term due to risk of dependence and interference with central compensation 1, 3

• Antiemetics: For associated nausea/vomiting

  • Metoclopramide, promethazine, ondansetron 3, 4

Important Considerations

• Avoid long-term vestibular suppressants: They interfere with central compensation and vestibular rehabilitation 1

• Treatment failures: Evaluate for:

  1. Persistent BPPV (repeat CRP)
  2. Incorrect canal identification
  3. CNS disorders masquerading as BPPV (found in 3% of treatment failures) 1
  4. Coexisting vestibular dysfunction 1

• Fall risk: BPPV increases fall risk, especially in older adults, affecting quality of life and potentially causing secondary injuries 1

• Recurrence: BPPV has a significant recurrence rate; patient education about recognizing symptoms and seeking prompt treatment is essential 1

Patient Education

Patients should be counseled about:

• Safety concerns, especially fall risk
• Potential for disease recurrence
• Importance of follow-up
• Driving precautions when taking medications that cause drowsiness 2

Vertigo treatment should focus on addressing the underlying cause rather than symptom suppression alone, with the goal of reducing morbidity, improving quality of life, and preventing complications such as falls.