What are the treatment options for vertigo?

Treatment Options for Vertigo

The treatment of vertigo should be directed at the underlying cause, with canalith repositioning procedures (CRPs) being the first-line therapy for benign paroxysmal positional vertigo (BPPV), which is the most common cause of vertigo. 1

Diagnosis and Classification

Before initiating treatment, it's essential to determine whether vertigo is:

1. Peripheral vertigo (inner ear origin):

   • Characterized by rotational vertigo with sudden onset
   • May include hearing loss, tinnitus, or aural fullness
   • Symptoms provoked by position changes
   • Nystagmus that suppresses with visual fixation
   • Normal neurological exam 1

2. Central vertigo (brain origin):

   • Gradual onset
   • Persistent symptoms
   • Associated neurological symptoms
   • Nystagmus that doesn't suppress with fixation
   • Abnormal neurological exam 1

Treatment Options by Specific Conditions

1. Benign Paroxysmal Positional Vertigo (BPPV)

BPPV is diagnosed when vertigo with torsional, upbeating nystagmus is provoked by the Dix-Hallpike maneuver 2.

First-line treatment:

• Canalith Repositioning Procedures (CRPs):
  • Epley maneuver: 90.7% success rate for posterior canal BPPV 1
  • Gufoni Maneuver: 93% success rate for lateral canal BPPV 1
  • Barbecue Roll Maneuver (Lempert): 75-90% success rate for lateral canal BPPV 1

Additional options:

• Self-administered CRP (modified Epley): 64% improvement rate 1
• Vestibular rehabilitation exercises: As adjunctive therapy or when CRPs fail 1

Important: Vestibular suppressants should NOT be used routinely for BPPV 1

2. Ménière's Disease

Treatment options:

• Lifestyle modifications and dietary changes 1
• Pharmacotherapy:
  • Diuretics and/or betahistine for maintenance therapy 2
  • Intratympanic steroids for active disease not responsive to noninvasive treatment 2

Note: Positive pressure therapy is NOT recommended for Ménière's disease 2

3. Vestibular Neuritis

Treatment approach:

• Vestibular suppressants for acute phase only
• Vestibular rehabilitation for recovery 1

Pharmacological Options for Symptom Management

1. For acute vertigo attacks:

   • Meclizine: 25 mg to 100 mg daily in divided doses 3
   • Levo-sulpiride i.v., 50 mg in 250 physiologic solution, once or twice a day 4
   • Methoclopramide i.m., 10 mg once or twice a day 4
   • Diazepam i.m., 10 mg once or twice a day, to decrease internuclear inhibition 4

2. For nausea and vomiting:

   • Prokinetic antiemetics (domperidone, metoclopramide) may help manage nausea without significantly interfering with vestibular compensation 1

Important cautions with medications:

• First-generation antihistamines have anticholinergic properties that can cause sedation, cognitive impairment, and increase fall risk, particularly in elderly patients 1
• Second-generation antihistamines are ineffective for vestibular suppression due to limited ability to cross the blood-brain barrier 1
• Meclizine may cause drowsiness; use caution when driving or operating machinery 3
• Coadministration of meclizine with other CNS depressants, including alcohol, may increase CNS depression 3

Patient Education and Safety

• Inform patients about safety concerns and fall prevention 1
• Educate about potential for recurrence and importance of follow-up 2
• During acute vertigo episodes, patients should:
  • Lie on their healthy side with head and trunk raised 20 degrees
  • Stay in a quiet but not darkened room 4

Special Considerations for Elderly Patients

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

By identifying the specific cause of vertigo and implementing targeted treatment strategies, most patients can experience significant symptom relief and improved quality of life.