What are the diagnostic and treatment options for a patient with long-term vertigo?

Management of Long-Term Vertigo

For patients with long-term vertigo, the first step is to determine the specific cause through targeted diagnostic testing, followed by appropriate treatment based on the diagnosis, with Benign Paroxysmal Positional Vertigo (BPPV) and Ménière's disease being the most common causes requiring different management approaches.

Diagnostic Approach

Step 1: Differentiate Between Peripheral and Central Vertigo

• Peripheral vertigo characteristics: Rotational vertigo with sudden onset, associated hearing loss/tinnitus/aural fullness, position-provoked symptoms, nausea/vomiting, and nystagmus that suppresses with visual fixation 1
• Central vertigo characteristics: Gradual onset, persistent symptoms, associated neurological symptoms, nystagmus that doesn't suppress with fixation, and abnormal neurological exam 1

Step 2: Specific Diagnostic Tests

1. Dix-Hallpike test: Gold standard for diagnosing posterior canal BPPV 2
2. Supine roll test: For diagnosing horizontal canal BPPV 2
3. Audiometric testing: Essential for diagnosing Ménière's disease 2
4. Imaging:
   • For peripheral vertigo: CT temporal bone or MRI head/internal auditory canal
   • For central vertigo: MRI head/internal auditory canal 1

Step 3: Identify Specific Vertigo Conditions

Common causes of long-term vertigo include:

1. BPPV: Characterized by brief episodes (seconds to minutes) of vertigo triggered by position changes 2
2. Ménière's disease: Episodes lasting 20 minutes to 12 hours with fluctuating hearing loss, tinnitus, and aural fullness 2
3. Vestibular migraine: Attacks lasting hours with photophobia, less likely to have hearing loss 2
4. Vestibular neuritis: Sudden severe vertigo lasting days without hearing loss 1

Treatment Approach

For BPPV (Most Common Cause)

1. First-line treatment: Canalith Repositioning Procedures (CRPs) 2, 1

   • Posterior canal BPPV: Epley maneuver (90.7% success rate) 1
   • Lateral canal BPPV: Gufoni maneuver (93% success rate) or Barbecue Roll maneuver (75-90% effectiveness) 1

2. Self-administered treatments:

   • Self-administered modified Epley (64% improvement)
   • More effective than Brandt-Daroff exercises (23% improvement) 1

3. Follow-up: Reassess within 1 month to document resolution or persistence 1

For Ménière's Disease

1. Diagnosis: Two or more spontaneous attacks of vertigo (20 minutes to 12 hours), documented low-to-midfrequency sensorineural hearing loss, fluctuating aural symptoms, and exclusion of other causes 2

2. Treatment approach:

   • Focus on preventing or reducing attack frequency and severity
   • Lifestyle modifications and medical therapies may be needed indefinitely 1
   • Follow-up to determine level of vertigo control and adjust therapy accordingly 2

Medication Management

1. For symptomatic relief: Meclizine 25-100 mg daily in divided doses 3

   • Caution: May cause drowsiness; patients should avoid driving and alcohol 3
   • Contraindications: Use with caution in patients with asthma, glaucoma, or prostate enlargement 3

2. Important medication principles:

   • Vestibular suppressants should NOT be used routinely for BPPV 1
   • Prokinetic antiemetics (domperidone, metoclopramide) may help manage nausea without interfering with vestibular compensation 1

Special Considerations

For Chronic/Persistent Vertigo

• Consider vestibular rehabilitation, especially when CRPs fail 1
• Assess for associated symptoms like neck pain, headache, and fatigue, which are common in chronic BPPV 4
• For intractable BPPV (>12 months duration), surgical options like posterior semicircular canal occlusion may be considered as a last resort 5

Patient Education and Safety

• Inform patients about fall risk and prevention strategies 2, 1
• Educate about potential recurrence (5-13.5% at 6 months, 10-18% at 1 year) 2
• Recommend regular physical activity to improve balance and coordination 1

Follow-up and Monitoring

• Baseline assessment of all clinical symptoms to evaluate effectiveness of therapy 2
• More frequent follow-up for severe or progressive disease 2
• Consider quality of life measures to evaluate long-term effect of interventions 2

Remember that vertigo treatment should focus not just on symptom suppression but on addressing the underlying cause whenever possible, with the ultimate goals of reducing morbidity, improving quality of life, and preventing recurrence.