What are the treatment options for vertigo?

Treatment Options for Vertigo

The most effective treatment for vertigo depends on the underlying cause, with canalith repositioning procedures (such as the Epley maneuver) being the first-line treatment for benign paroxysmal positional vertigo (BPPV) with success rates of 61-95% after a single treatment. 1

Diagnosis and Classification

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

1. BPPV (Benign Paroxysmal Positional Vertigo)

   • Characterized by brief episodes triggered by specific head movements
   • Diagnosed using the Dix-Hallpike maneuver (posterior canal) or Supine roll test (horizontal canal) 1
   • No routine imaging or vestibular testing needed unless additional symptoms present 1

2. Ménière's Disease

   • Features episodic vertigo, fluctuating hearing loss, tinnitus, and aural fullness 2
   • Episodes typically last hours

3. Vestibular Neuritis/Labyrinthitis

   • Sudden onset of prolonged vertigo (days)
   • May include hearing loss in labyrinthitis

Treatment by Cause

BPPV Treatment

1. Canalith Repositioning Procedures

   • Epley maneuver (first-line): 61-95% success after single treatment 1
   • Alternative maneuvers: Semont (Liberatory), Gufoni, or Lempert (Barbecue Roll) with 71-94% success rates 1
   • Repeat maneuvers can increase success to 90-98% 2
   • No postprocedural restrictions needed 1

2. Self-administered Options

   • Self-administered CRP (64% improvement) more effective than Brandt-Daroff exercises (23% improvement) 1

3. Vestibular Rehabilitation

   • Less effective than repositioning maneuvers for BPPV but may help with chronic imbalance 1

Pharmacological Treatment

1. For Acute Vertigo Symptoms

   • Meclizine: 25-100 mg daily in divided doses for vestibular vertigo 3
   • Diazepam: 2-5 mg orally 1-3 times daily as needed (alternative when meclizine fails) 1
     • Lower doses (2 mg) for elderly patients
     • Limit to short-term use (≤1 week) to prevent dependence
   • Prochlorperazine: 25 mg oral or suppository for managing associated nausea 1

2. For Ménière's Disease

   • Diuretics and/or betahistine to reduce symptoms or prevent attacks 1
   • Sodium restriction (less than 2g/day) 1

3. For Labyrinthitis with Hearing Loss

   • Oral prednisone (starting at 60 mg daily with taper over 10-14 days) 1
   • Intratympanic steroid injections for persistent symptoms 1

Persistent or Refractory Vertigo

For patients with Ménière's disease who fail medical management:

• Intratympanic gentamicin may be considered 2
• Labyrinthectomy may be offered for patients with nonusable hearing and persistent vertigo (>95% success rate) 2

Lifestyle Modifications

• Limit salt/sodium intake (<2g/day)
• Avoid excessive caffeine, alcohol, and nicotine
• Manage stress
• Ensure adequate sleep 1

Follow-up

• Reassess patients within 1 month after treatment to confirm symptom resolution 2, 1
• Evaluate for persistent symptoms that may indicate:
  • Treatment failure
  • Coexisting vestibular conditions
  • Serious CNS disorders 1

Patient Education

• Discuss safety concerns related to vertigo
• Inform about potential for disease recurrence (approximately 36%) 1
• Emphasize importance of follow-up

Special Considerations

• Elderly patients are at higher risk of falls and require careful medication management 1
• Patients with physical limitations may require modified examination techniques 1
• Monitor for medication side effects, particularly sedation and confusion with vestibular suppressants

By following this treatment approach based on proper diagnosis, most patients with vertigo can experience significant symptom improvement and enhanced quality of life.