What is the treatment for headache and vertigo?

Treatment of Headache and Vertigo

The treatment of headache and vertigo should be based on identifying the underlying cause, with first-line therapy for vertigo being repositioning maneuvers for BPPV or vestibular suppressants like meclizine for other vestibular disorders, while migraine-associated vertigo requires migraine-specific treatment with NSAIDs or triptans for acute attacks and beta-blockers or anticonvulsants for prevention. 1

Diagnostic Considerations

Before initiating treatment, it's crucial to determine the underlying cause of headache and vertigo, as treatment approaches differ significantly:

1. Benign Paroxysmal Positional Vertigo (BPPV)

   • Characterized by brief episodes of vertigo triggered by head position changes
   • Diagnosed with Dix-Hallpike maneuver

2. Ménière's Disease

   • Features episodic vertigo, fluctuating hearing loss, tinnitus, and aural fullness
   • Attacks typically last hours

3. Vestibular Migraine

   • Recurrent vertigo attacks in patients with migraine history
   • Vertigo may occur with or without headache
   • Affects approximately 3.2% of the population 2

4. Other causes: Central vertigo, vestibular neuritis, medication side effects

Treatment Algorithm

1. For BPPV

• First-line: Canalith repositioning procedures (Epley or Semont maneuvers)
• Avoid: Vestibular suppressant medications as they delay central compensation 1
• Follow-up: Reassess within 1 month to confirm symptom resolution 1

2. For Ménière's Disease

• First-line:

  • Dietary modifications: Low-sodium diet (1500-2300 mg daily)
  • Limit alcohol and caffeine intake 1

• Medications:

  • Diuretics to reduce endolymphatic hydrops
  • Meclizine for acute vertigo attacks 1, 3
  • Antihistamines for symptomatic relief

• For refractory cases:

  • Middle ear injections (steroids or gentamicin)
  • Surgical options for severe cases (endolymphatic sac decompression, vestibular nerve section, or labyrinthectomy) 1

3. For Migraine-Associated Vertigo

• Acute treatment:

  • NSAIDs (aspirin, ibuprofen, naproxen sodium) as first-line therapy 1
  • Triptans if NSAIDs are ineffective 1
  • Antiemetics for associated nausea and vomiting 1
  • Non-oral routes for patients with significant nausea/vomiting 1

• Preventive treatment (for ≥2 attacks/month with significant disability):

  • First-line: Propranolol (80-240 mg/day) or timolol (20-30 mg/day) 1
  • Alternative options: Amitriptyline (30-150 mg/day), divalproex sodium (500-1500 mg/day) 1
  • For pregnant patients: Propranolol is first choice when prophylaxis is necessary 4

• Non-pharmacological approaches:

  • Trigger avoidance (stress, sleep deprivation, hormonal changes) 1, 5
  • Vestibular rehabilitation 5

4. For Acute Vertigo of Uncertain Etiology

• Symptomatic relief:
  • Meclizine 12.5-25 mg every 4-6 hours as needed for vertigo 3
  • Limit use to short-term management of severe symptoms 1
  • Consider antiemetics for associated nausea

Special Populations

Pregnant Women

• Acute treatment:

  • Paracetamol as first-line for migraine headache
  • NSAIDs only in second trimester
  • Avoid vestibular suppressants if possible 4

• Preventive treatment:

  • Avoid medications unless experiencing ≥3 severe attacks monthly
  • Propranolol (80-160 mg daily) is first choice when necessary 4

Important Caveats

1. Avoid prolonged use of vestibular suppressants as they may delay central compensation and vestibular rehabilitation 1

2. Watch for medication overuse headache when treating migraine-associated vertigo with frequent analgesics or triptans 1

3. Consider comorbidities when selecting treatments:

   • Avoid beta-blockers in patients with asthma or heart block
   • Use caution with anticonvulsants in patients with liver disease

4. Diagnostic challenges: Vertigo and headache may not occur simultaneously in vestibular migraine, making diagnosis difficult 5, 6

5. Treatment efficacy for vestibular migraine has not been validated by properly controlled clinical trials 2

By following this structured approach to the treatment of headache and vertigo, clinicians can provide effective symptom relief while addressing the underlying cause of these often debilitating symptoms.