What is the treatment guideline for vertigo?

Treatment Guidelines for Vertigo

The primary treatment for benign paroxysmal positional vertigo (BPPV), the most common cause of vertigo, should be particle repositioning maneuvers (PRMs) rather than medication. 1

Diagnosis and Classification

Before initiating treatment, it's essential to determine the specific type of vertigo:

1. BPPV (Benign Paroxysmal Positional Vertigo)

   • Characterized by brief episodes of vertigo triggered by changes in head position
   • Diagnosed using the Dix-Hallpike maneuver for posterior canal BPPV
   • Supine roll test for lateral canal BPPV if Dix-Hallpike is negative but history is suggestive

2. Other peripheral causes

   • Vestibular neuritis/labyrinthitis
   • Ménière's disease

3. Central causes

   • Vertebrobasilar ischemia
   • CNS disorders

Treatment Algorithm for BPPV

First-Line Treatment

• Canalith Repositioning Procedures (CRPs)/Particle Repositioning Maneuvers (PRMs) 1
  • For posterior canal BPPV: Epley maneuver or Semont maneuver
  • For lateral canal BPPV: Roll maneuvers (Lempert/barbecue roll)
  • Success rates reach 90-98% with repeated maneuvers 1

Second-Line Treatment

• Vestibular rehabilitation exercises 1
  • Can be self-administered or clinician-guided
  • Particularly useful for patients with balance deficits or incomplete resolution

Important Recommendations Against

• Avoid routine use of vestibular suppressant medications 1
  • Antihistamines (e.g., meclizine)
  • Benzodiazepines
  • These medications may delay central compensation and recovery

Follow-up

• Reassessment within 1 month after initial treatment 1
  • To confirm symptom resolution
  • To identify treatment failures requiring additional intervention

Treatment for Other Causes of Vertigo

Vestibular Neuritis/Labyrinthitis

• Brief use of vestibular suppressants during acute phase only 2
• Vestibular rehabilitation exercises for promoting compensation

Ménière's Disease

• Salt restriction and diuretics 2, 3
• Vestibular suppressants during acute attacks only

Migraine-Associated Vertigo

• Prophylactic medications: calcium channel blockers, tricyclic antidepressants, beta-blockers 2

Pharmacological Treatment (When Indicated)

Meclizine is FDA-approved for "treatment of vertigo associated with diseases affecting the vestibular system in adults" 4, but should be used judiciously and not as first-line treatment for BPPV.

Common vestibular suppressants:

• Meclizine: 25-100 mg daily in divided doses 4
  • Side effects: drowsiness, dry mouth
  • Caution: may impair driving ability
  • Contraindicated in patients with glaucoma, prostatic hypertrophy, or asthma due to anticholinergic effects

Management of Treatment Failures

For patients who fail initial treatment:

1. Re-evaluate diagnosis - confirm persistent BPPV with appropriate positional testing 1
2. Repeat repositioning maneuvers - if Dix-Hallpike or supine roll test remains positive 1
3. Consider alternate canal involvement - check for canal conversion 1
4. Evaluate for other vestibular disorders or CNS pathology if symptoms persist despite repeated maneuvers 1
5. Consider imaging (MRI) only if:
   • Atypical nystagmus patterns
   • Neurological symptoms present
   • Failed response to multiple properly performed repositioning maneuvers 1

Common Pitfalls to Avoid

1. Overreliance on medications - vestibular suppressants may delay central compensation and recovery 1
2. Failure to reassess - patients should be reevaluated within one month to confirm resolution 1
3. Missing central causes - persistent symptoms despite proper treatment should prompt evaluation for CNS disorders 1
4. Inappropriate imaging - routine radiographic imaging is not recommended for typical BPPV 1
5. Prolonged medication use - vestibular suppressants should be used briefly and only when necessary 2

Remember that BPPV has a high rate of recurrence (about 15% per year), so patient education about possible recurrence and when to seek retreatment is essential 1.