How is vertigo treated?

Treatment of Vertigo

The most effective treatment for vertigo depends on its specific cause, with canalith repositioning procedures (CRPs) like the Epley maneuver being the first-line treatment for benign paroxysmal positional vertigo (BPPV), rather than medication. 1

Diagnosis and Classification

Vertigo can be classified based on triggers and timing into three main categories:

1. Benign Paroxysmal Positional Vertigo (BPPV)

   • Diagnosed when vertigo with torsional, upbeating nystagmus is provoked by the Dix-Hallpike maneuver 2
   • Characterized by brief episodes of vertigo triggered by head position changes

2. Ménière's Disease

   • Presents with episodic vertigo, fluctuating hearing loss, tinnitus, and aural fullness 2
   • Episodes are spontaneous and unpredictable

3. Vestibular Neuritis

   • Presents as sudden onset of prolonged vertigo
   • Not associated with hearing loss

Treatment Approaches

For BPPV (First-line):

• Canalith Repositioning Procedures (80-90% success rate) 1
  • Epley maneuver for posterior canal BPPV
  • Semont maneuver as an alternative
  • Should be performed before considering medication

For Ménière's Disease:

• Lifestyle modifications:
  • Salt restriction
  • Diuretics
• Symptom management during acute attacks:
  • Vestibular suppressants (short-term use only)
  • Antiemetics for nausea control

For Vestibular Neuritis:

• Vestibular rehabilitation exercises - improve compensation and decrease recurrence rates, especially in elderly patients 1
• Short-term medication for symptom relief

Medication Considerations

• Vestibular suppressants should NOT be used routinely for BPPV as they:

  • May interfere with vestibular compensation 1
  • Are less effective than repositioning maneuvers
  • Should be limited to short-term symptom relief while awaiting definitive treatment

• When medications are necessary:

  • Meclizine: 25 mg to 100 mg daily in divided doses 3
    • May cause drowsiness; caution with driving or operating machinery
    • Use with care in patients with asthma, glaucoma, or prostate enlargement due to anticholinergic effects

• For nausea and vomiting:

  • Prokinetic antiemetics (domperidone, metoclopramide) may be useful adjuncts without significantly interfering with vestibular compensation 1

Follow-up and Monitoring

Clinicians should document resolution, improvement, or worsening of vertigo, tinnitus, and hearing loss after treatment, as well as any changes in quality of life 2. This follow-up is crucial to:

• Evaluate for other disease etiologies
• Identify patients who would benefit from increased or decreased intensity of therapy
• Reduce the use of ineffective therapy

Special Considerations

• Fall risk: Patients should be counseled about safety concerns and fall prevention 1
• Recurrence: BPPV has a recurrence rate of approximately 15% per year 2, and patients should be informed about this possibility
• Elderly patients: Require lower medication doses due to higher fall risk; vestibular rehabilitation is particularly beneficial 1

Treatment Failures

If symptoms persist after appropriate treatment:

• Evaluate for unresolved BPPV
• Consider underlying peripheral vestibular or central nervous system disorders 2
• Consider neuroimaging if central causes are suspected

Remember that vertigo treatment should focus on addressing the underlying cause rather than simply suppressing symptoms, with the goal of improving quality of life and reducing the risk of falls.