What are the treatment options for vertigo?

Treatment Options for Vertigo

The most effective treatment for vertigo depends on the underlying cause, with canalith repositioning procedures (CRPs) being the first-line treatment for BPPV, which has an 80-90% success rate with 1-2 treatments. 1

Diagnosis-Based Treatment Approach

Benign Paroxysmal Positional Vertigo (BPPV)

• First-line treatment: Canalith Repositioning Procedures (CRPs)
  • Epley maneuver for posterior canal BPPV
  • Barbecue roll maneuver for lateral canal BPPV
  • Gufoni maneuver for certain variants
  • Success rate: 80-90% with 1-2 treatments 1
• Vestibular rehabilitation: Can be self-administered or clinician-guided, particularly beneficial for elderly patients 1
• Observation with follow-up: BPPV can resolve spontaneously in some cases 1

Vestibular Neuritis/Labyrinthitis

• Short course of steroids may be beneficial
• Vestibular rehabilitation is recommended 1

Ménière's Disease

• High-dose, long-term betahistine 2
• Dietary modifications (low salt)
• Diuretics in some cases

Vestibular Migraine

• Prophylaxis with beta-blockers, anticonvulsants, or antidepressants 1
• Trigger avoidance
• Migraine-specific treatments

Pharmacological Management

Symptomatic Relief

• Meclizine: 25-100 mg daily in divided doses for vertigo associated with vestibular system diseases 3
  • Common side effects: drowsiness, dry mouth, headache, fatigue
  • Caution: may cause drowsiness; avoid driving or operating machinery
  • Contraindicated in patients with hypersensitivity to meclizine 3

Additional Medication Options

• Dopamine receptor antagonists for patients not responding to meclizine:

  • Prochlorperazine (5-10 mg PO TID)
  • Metoclopramide (5-10 mg PO QID)
  • Haloperidol (0.5-2 mg PO daily-BID)
  • Olanzapine (2.5-5 mg PO daily) 1

• For anxiety-related dizziness: Lorazepam (0.5-1 mg q4h PRN) 1

• For refractory symptoms:

  • Combination therapy with 5-HT3 antagonists (e.g., ondansetron)
  • Corticosteroids (dexamethasone 4-8 mg BID-TID), especially with suspected CNS involvement 1

Non-Pharmacological Approaches

Vestibular Rehabilitation

• Effective for vestibular hypofunction
• Can be self-administered or directed by a physical therapist
• May decrease recurrence rates, particularly beneficial for elderly patients 1, 4

Lifestyle Modifications

• Regular physical activity (cardio-exercise for at least 30 minutes twice weekly)
• Home safety assessment to prevent falls 1

Treatment Failures and Follow-Up

• Patients should be reassessed within 1 month after initial treatment 1
• For persistent BPPV despite treatment:
  • Consider examination for involvement of other semicircular canals
  • Evaluate for incorrect diagnosis or underlying CNS disorders 5
• When BPPV symptoms are atypical or refractory to treatment:
  • Obtain additional history and physical examination
  • Consider neurological examination, CNS testing, and/or MRI of brain and posterior fossa 5

Patient Education

• Counsel patients about:
  • Increased fall risk, especially in elderly patients
  • Potential for disease recurrence (BPPV recurrence rate: approximately 15% per year)
  • Importance of follow-up 5, 1
• Early recognition of recurrent symptoms allows for prompt treatment 5

Special Considerations

• Elderly patients: May benefit more from combined vestibular rehabilitation and CRPs 1
• Patients with mobility issues: May require assistance or modified techniques 1
• Drug interactions: Avoid co-administration of meclizine with other CNS depressants, including alcohol, as this may increase CNS depression 3
• Medication cautions: Use meclizine with care in patients with history of asthma, glaucoma, or prostate enlargement due to potential anticholinergic effects 3

Common Pitfalls to Avoid

• Unnecessary imaging (CT or MRI) for diagnosing BPPV 1
• Overlooking multiple canal involvement in BPPV 1
• Inadequate follow-up 1
• Failing to recognize central causes of vertigo that may mimic BPPV (occurs in approximately 3% of treatment failures) 5