What is the treatment for vestibular paroxysm?

Treatment of Vestibular Paroxysm

The first-line treatment for vestibular paroxysmia is sodium channel blockers, with oxcarbazepine being the preferred medication due to its superior efficacy and tolerability compared to carbamazepine. 1, 2

Pharmacological Management

First-Line Treatment

• Sodium channel blockers:
  • Oxcarbazepine: Start with 300 mg once daily for the first week, increase to 300 mg twice daily in the second week, and 300 mg three times daily by the third week 2
  • Carbamazepine: Alternative option, but has more side effects than oxcarbazepine 1, 3
  • Lacosamide: Can be considered as an alternative sodium channel blocker 1

Adjunctive Therapy

• Betahistine mesilate tablets: Can be used as an augmentation therapy with either oxcarbazepine or carbamazepine 4
  • The combination of carbamazepine with betahistine has shown greater reduction in vertigo frequency, duration, and intensity compared to carbamazepine alone 4

Non-Pharmacological Management

For Benign Paroxysmal Positional Vertigo (BPPV)

If the vestibular paroxysm is due to BPPV:

1. Canalith Repositioning Procedures (CRP):

   • Epley maneuver: Most validated technique with 61-95% success rate after a single treatment 5
   • Alternative maneuvers: Semont maneuver (Liberatory), Gufoni Maneuver, and Lempert maneuver (Barbecue Roll) with success rates of 71-94% 5
   • Repeat procedures can increase success rates to 90-98% 5

2. Vestibular Rehabilitation Therapy (VRT):

   • Recommended as adjunctive therapy for:
     • Elderly patients with residual dizziness after successful CRP
     • Patients with preexisting balance deficits
     • Patients with CNS disorders
     • Patients at increased risk of falling 5

Special Considerations

Medication Side Effects

• Monitor for side effects of sodium channel blockers:
  • Oxcarbazepine has fewer side effects compared to carbamazepine 2
  • Common side effects include dizziness, nausea, headache, and fatigue 3

Surgical Options

• Microsurgical decompression:
  • Effective for secondary vestibular paroxysmia
  • Consider only when medication is not tolerated in classical or idiopathic vestibular paroxysmia 1

Patient Monitoring

• Reassess patients within 1 month after treatment to document resolution or persistence of symptoms 5
• Be aware of potential recurrence (approximately 36% recurrence rate for BPPV) 5

Diagnostic Considerations

• High-resolution MRI sequences (CISS/FIESTA) of the cerebello-pontine angle may support diagnosis of vestibular paroxysmia 1
• Positive response to sodium channel blockers is the most reliable clinical sign for confirming diagnosis 1, 6

Patient Education

• Provide information on lifestyle modifications:
  • Sodium restriction
  • Avoiding excessive caffeine, alcohol, and nicotine
  • Stress management
  • Adequate sleep 5
• Educate about safety concerns, potential for disease recurrence, and importance of follow-up 5

Caution

• The American Academy of Otolaryngology-Head and Neck Surgery recommends against routine prescription of vestibular suppressant medications for BPPV 5
• Limited short-term use of vestibular suppressants only for:
  • Severe autonomic symptoms
  • Patients who refuse CRP
  • Severe symptoms after CRP 5

Remember that vestibular paroxysmia is a rare condition characterized by brief episodes of vertigo lasting seconds to minutes, often triggered by head movements, and proper diagnosis is essential for effective treatment 1, 6.