What is the best approach to manage long COVID-induced vertigo?

Management of Long COVID-Induced Vertigo

For long COVID-induced vertigo, a vestibular rehabilitation therapy program combined with symptomatic treatment using meclizine (25-100 mg daily in divided doses) is the recommended first-line approach.

Understanding Long COVID-Induced Vertigo

Long COVID can cause various neurological symptoms, with vertigo being one of the recognized manifestations. According to the European Society of Clinical Microbiology and Infectious Diseases (ESCMID) guidelines, audiovestibular manifestations of long COVID include tinnitus, hearing loss, and vertigo 1. The pathophysiology may involve:

• Inner ear damage leading to vestibular dysfunction
• Central nervous system involvement due to the neurotropic effect of SARS-CoV-2
• Post-infectious inflammation of nervous tissue
• Possible autoimmune mechanisms

Diagnostic Approach

Before initiating treatment, it's essential to:

1. Confirm COVID-19 association: Document prior COVID-19 infection within the past 6 months
2. Rule out other causes: Exclude other serious conditions that may cause vertigo
3. Determine vestibular involvement: Look for:
   • Spontaneous nystagmus (present in 13.8% of post-COVID vertigo patients) 2
   • Positional nystagmus (present in 24.1% of cases) 2
   • Asymmetrical optokinetic nystagmus (31% of cases) 2
   • Unilateral weakness on vestibular testing (39.7% of cases) 2

Treatment Protocol

First-Line Treatment:

1. Pharmacological Management:

   • Meclizine: 25-100 mg daily in divided doses 3
     • FDA-approved for treatment of vertigo associated with vestibular system diseases
     • May cause drowsiness; caution patients about driving or operating machinery
     • Use with care in patients with asthma, glaucoma, or prostate enlargement due to anticholinergic effects

2. Vestibular Rehabilitation Therapy:

   • Individualized exercise program to promote central compensation
   • Can be delivered via telehealth when in-person visits are difficult 4
   • Includes habituation, gaze stabilization, and balance exercises

For Specific BPPV-Type Vertigo:

If the vertigo has characteristics of Benign Paroxysmal Positional Vertigo (BPPV), which can occur post-COVID:

• Consider canalith repositioning procedures (Epley maneuver)
• These can be guided remotely via telehealth in pandemic situations 4

For Persistent Symptoms:

For patients with persistent vertigo despite first-line treatment:

• Consider short course of oral corticosteroids (prednisone) 5
• This approach has shown benefit in cases of COVID-19-induced vestibular neuritis

Monitoring and Follow-Up

• Assess response to treatment within 2 weeks
• Note that vertigo attacks may persist for up to two weeks after COVID-19 symptoms resolve, even with medication 6
• Monitor for improvement in:
  • Frequency and severity of vertigo episodes
  • Associated symptoms (nausea, vomiting)
  • Functional capacity and quality of life

Important Considerations

• Medication Cautions:

  • Meclizine may interact with other CNS depressants, including alcohol, increasing CNS depression 3
  • As meclizine is metabolized by CYP2D6, be aware of potential interactions with CYP2D6 inhibitors 3

• Central vs. Peripheral Origin:

  • Research indicates that post-COVID vertigo may have both peripheral and central components 2
  • In some studies, up to 51.5% of patients had vertical or oblique nystagmus suggesting central involvement 7

• Long-Term Prognosis:

  • Patients who have had COVID-19 may compensate more slowly from vertigo/dizziness 2
  • Some may experience vertigo as a late complication due to post-infectious inflammation 2

Special Populations

For patients with severe, refractory symptoms or those with significant functional impairment, consider referral to a neurotology specialist for comprehensive vestibular assessment and advanced treatment options.