What is the treatment for vertigo?

Treatment of Vertigo

The most effective treatment for vertigo depends on its underlying cause, with canalith repositioning procedures (CRPs) such as the Epley maneuver being the first-line treatment for benign paroxysmal positional vertigo (BPPV), which is the most common cause of vertigo. 1

Diagnosis

Before initiating treatment, proper diagnosis is essential:

• Dix-Hallpike test: Gold standard for diagnosing posterior canal BPPV (positive when vertigo with torsional, upbeating nystagmus is provoked) 2, 1
• Supine roll test: For diagnosing lateral (horizontal) canal BPPV 1
• HINTS examination (Head-Impulse, Nystagmus, Test of Skew): More sensitive than early MRI for detecting stroke in patients with vertigo (100% vs 46%), useful for distinguishing peripheral from central causes 1

Treatment Algorithm Based on Cause

1. Benign Paroxysmal Positional Vertigo (BPPV)

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

  • Epley maneuver for posterior canal BPPV (success rate: 80-90%)
  • Barbecue roll or Gufoni maneuver for lateral canal BPPV
  • Usually effective with 1-2 treatments

• Alternative options:

  • Vestibular rehabilitation (self-administered or clinician-guided)
  • Observation with follow-up (BPPV may resolve spontaneously in some cases)

2. Vestibular Neuritis

• Acute management: Brief use of vestibular suppressants 3
  • Anticholinergics
  • Benzodiazepines (e.g., diazepam 10 mg IM once or twice daily)

3. Ménière's Disease

• Preventive measures:

  • Salt restriction
  • Diuretics

• During acute attacks:

  • Vestibular suppressants (anticholinergics, benzodiazepines) 3

4. Vestibular Migraine

• Prophylactic agents 3:
  • L-channel calcium channel antagonists
  • Tricyclic antidepressants
  • Beta-blockers

5. Pharmacological Management for Symptomatic Relief

• Meclizine (antihistamine): 25-100 mg daily in divided doses for vertigo associated with vestibular system diseases 4

  • Caution: May cause drowsiness; use care when driving or operating machinery
  • Contraindicated in patients with hypersensitivity to meclizine

• Antiemetics for nausea/vomiting:

  • Prokinetic antiemetics (domperidone, metoclopramide) 1
  • Levo-sulpiride, metoclopramide, or triethilperazine to reduce neurovegetative symptoms 5

• Other options:

  • Gabapentin (300 mg 2-3 times daily) to reduce nystagmus and stabilize visual field 5
  • Magnesium sulfate IV or piracetam IV to decrease vestibular damage 5

Follow-up and Monitoring

• Reassess patients within 1 month after initial treatment to confirm symptom resolution 2, 1
• Evaluate treatment failures for:
  • Persistent BPPV
  • Incorrect diagnosis
  • Underlying peripheral vestibular or CNS disorders

Important Considerations and Caveats

• Recurrence risk: Approximately 36% for BPPV; patients should be counseled about this possibility 1

• Fall risk: Particularly increased in elderly patients with untreated vertigo 1

• Medication cautions:

  • Vestibular suppressants may delay vestibular compensation if used long-term 3
  • Anticholinergic effects: Use with care in patients with asthma, glaucoma, or prostate enlargement 4
  • CNS depression: Avoid co-administration with other CNS depressants including alcohol 4

• Patient positioning during acute vertigo: Patients should lie on their healthy side with head and trunk raised 20 degrees; room should be quiet but not darkened 5

• Physical therapy: Vestibular rehabilitation can be beneficial, particularly for elderly patients, and may decrease recurrence rates 1

By following this evidence-based approach to vertigo treatment, clinicians can provide effective relief for patients while addressing the underlying cause of their symptoms.