What are the treatment options for vertigo?

Treatment Options for Vertigo

The first-line treatment for vertigo depends on the underlying cause, with Canalith Repositioning Procedures (CRPs) such as the Epley maneuver being the most effective treatment for Benign Paroxysmal Positional Vertigo (BPPV) with success rates up to 96% after two attempts. 1

Diagnosis-Based Treatment Approach

1. Benign Paroxysmal Positional Vertigo (BPPV)

• First-line treatment: Canalith Repositioning Procedures

  • Epley maneuver: 90.7% success rate after initial attempt 1
  • Gufoni maneuver: 93% success rate for geotropic type BPPV 1
  • Barbecue Roll maneuver (Lempert): 75-90% effective for lateral canal BPPV 1
  • Self-administered options:
    • Self-Epley: 64% improvement rate 1
    • Self-Semont: 58% resolution rate 1
    • Brandt-Daroff exercises: 23% improvement rate 1

• Vestibular rehabilitation exercises may be used as adjunctive therapy or when CRPs fail

  • These exercises fatigue the vestibular response and force central nervous system compensation 2
  • May decrease recurrence rates, especially in elderly patients 2
  • Less effective than CRPs in short-term but approaches similar effectiveness in long-term follow-up 2

2. Vestibular Neuritis/Labyrinthitis

• Acute management:
  • Vestibular suppressant medications for symptom control 3
  • Corticosteroids improve recovery (with 2-12% risk of recurrence) 4
  • Antiemetics for nausea control 3
• Followed by vestibular rehabilitation exercises 3

3. Ménière's Disease

• Dietary modifications: Low-salt diet (<1500-2300 mg/day) 1
• Medications:
  • Diuretics 5
  • Long-term high-dose betahistine (likely effective based on non-controlled studies) 4
  • Note: Episode frequency often decreases spontaneously over time (>5 years) 4

4. Vestibular Migraine

• Prophylactic medications:
  • L-channel calcium channel antagonists
  • Tricyclic antidepressants
  • Beta-blockers 6

5. Vestibular Paroxysmia

• First-line treatment: Carbamazepine 4

Pharmacological Treatment Options

Vestibular Suppressants

• Meclizine (FDA-approved for vertigo): 25-100 mg daily in divided doses 7

  • Caution: May cause drowsiness; use care when driving or operating machinery 7
  • Contraindicated in patients with hypersensitivity to meclizine 7
  • Potential anticholinergic effects: Use with caution in patients with asthma, glaucoma, or prostate enlargement 7

• Other medication classes used for vertigo:

  • Anticholinergics
  • Antihistamines
  • Benzodiazepines (particularly useful for anxiety-related vertigo)
  • Dopamine receptor antagonists 6

Important Considerations

• Avoid prolonged use of vestibular suppressants as they may interfere with central compensation 1
• Medication interactions: Coadministration of meclizine with other CNS depressants (including alcohol) may increase CNS depression 7
• CYP2D6 inhibitors may interact with meclizine 7
• Prokinetic antiemetics (domperidone, metoclopramide) are useful adjuncts for managing nausea/vomiting during vertigo attacks 1
• Vestibular rehabilitation has been shown to be safe and effective with no reported adverse effects in 21 randomized trials 2

Follow-up and Patient Education

• Reassess patients within 1 month to document resolution or persistence of symptoms 1
• Educate patients about:
  • Fall prevention strategies
  • Potential for recurrence (BPPV has a 50% long-term recurrence rate) 4
  • Lifestyle modifications including regular physical activity
  • Keeping a symptom journal to track triggers 1

Special Populations

• Elderly patients:

  • Higher risk of falls with untreated vestibular disorders
  • May require lower medication doses to avoid adverse effects 1
  • Vestibular rehabilitation may be particularly beneficial in reducing BPPV recurrence 2

• Patients with comorbidities that may limit vestibular rehabilitation:

  • Cervical stenosis
  • Severe rheumatoid arthritis
  • Cervical radiculopathies
  • Spinal conditions
  • Morbid obesity 2

The treatment of vertigo requires a targeted approach based on accurate diagnosis of the underlying cause. While medication can provide symptomatic relief, repositioning maneuvers and vestibular rehabilitation offer more definitive treatment for many forms of vertigo.