What is the treatment for vertigo?

Treatment of Vertigo

The treatment of vertigo should focus on particle repositioning maneuvers (PRMs) as first-line therapy for benign paroxysmal positional vertigo (BPPV), which is the most common cause of vertigo, with success rates of 90-98% when properly performed. 1

Diagnostic Approach

Before initiating treatment, proper diagnosis is essential:

1. Determine type of vertigo based on triggers and timing:

   • Positional vertigo: Triggered by head position changes (suggests BPPV)
   • Spontaneous episodic vertigo: Unprovoked episodes (suggests Ménière's disease or vestibular migraine)
   • Acute vestibular syndrome: Continuous vertigo with nausea/vomiting (suggests vestibular neuritis)

2. Key diagnostic tests:

   • Dix-Hallpike maneuver: For posterior canal BPPV diagnosis
   • Supine roll test: For lateral canal BPPV diagnosis

Treatment Algorithm for Vertigo

1. Benign Paroxysmal Positional Vertigo (BPPV)

• First-line: Canalith Repositioning Procedures (CRP)/Particle Repositioning Maneuvers (PRM)
  • Posterior canal: Epley or Semont maneuver
  • Lateral canal: Lempert/BBQ roll maneuver
  • Success rates reach 90-98% with repeated maneuvers 1
• Follow-up: Reassess within 1 month to confirm symptom resolution 1
• For persistent BPPV: Repeat repositioning maneuvers; consider examination for involvement of other canals 1

2. Acute Vestibular Syndrome/Vestibular Neuritis

• Symptomatic treatment:
  • Meclizine 25-100 mg daily in divided doses for short-term symptom relief 2
  • Limit use to acute phase only (first few days) to avoid delaying central compensation
• Rehabilitation: Vestibular rehabilitation exercises once acute symptoms subside

3. Ménière's Disease

• First-line: Lifestyle modifications
  • Sodium restriction
  • Avoidance of caffeine, alcohol, and tobacco
• Pharmacologic therapy during acute attacks:
  • Meclizine 25-100 mg daily in divided doses 2
• For recurrent attacks: Consider referral for specialized treatments (e.g., transtympanic injections) 1

4. Vestibular Migraine

• Acute treatment: Migraine-specific medications
• Preventive treatment: Standard migraine prophylaxis for frequent episodes

Important Considerations and Pitfalls

1. Avoid overuse of vestibular suppressants:

   • Medications like meclizine can cause drowsiness and impair driving/machinery operation 2
   • Prolonged use may delay central compensation and vestibular recovery
   • Use only for short-term symptomatic relief

2. Red flags requiring urgent evaluation:

   • Vertigo with neurological symptoms (dysarthria, diplopia, ataxia)
   • New-onset severe headache with vertigo
   • Vertical or direction-changing nystagmus
   • These may indicate central causes requiring neuroimaging 1

3. Treatment failures:

   • Reevaluate diagnosis if symptoms persist after appropriate treatment
   • Consider involvement of other semicircular canals in BPPV (canal conversion occurs in ~6% of cases) 1
   • Evaluate for coexisting vestibular disorders or CNS pathology (found in ~3% of BPPV treatment failures) 1

4. Patient education:

   • Instruct on safety precautions to prevent falls
   • Inform about potential for BPPV recurrence (20-30% recurrence rate)
   • Teach self-administered repositioning maneuvers for recurrences

By following this evidence-based approach to vertigo treatment, clinicians can effectively manage most cases, reduce morbidity, and improve quality of life for patients suffering from this common and often debilitating condition.