How is vertigo treated?

Treatment of Vertigo

The treatment of vertigo should be tailored to the specific underlying cause, with canalith repositioning procedures (CRPs) being the first-line treatment for benign paroxysmal positional vertigo (BPPV), which has a success rate of 80-90% with just 1-2 treatments. 1

Diagnosis and Classification

Before initiating treatment, proper diagnosis is essential:

• Diagnostic Approach:

  • The Dix-Hallpike test is the gold standard for diagnosing posterior canal BPPV 2, 1
  • The supine roll test is used for lateral (horizontal) canal BPPV 1
  • The HINTS examination (Head-Impulse, Nystagmus, Test of Skew) helps distinguish peripheral from central causes of vertigo 1

• Classification of Vertigo:

  • Acute Vestibular Syndrome
  • Triggered Episodic Vestibular Syndrome
  • Spontaneous Episodic Vestibular Syndrome
  • Chronic Vestibular Syndrome 1

Treatment Based on Specific Causes

1. Benign Paroxysmal Positional Vertigo (BPPV)

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

  • Epley maneuver for posterior canal BPPV
  • Barbecue roll maneuver for horizontal canal BPPV
  • Gufoni maneuver for certain variants

• Follow-up: Patients should be reassessed within 1 month after initial treatment to confirm symptom resolution 2, 1

2. Vestibular Neuritis/Labyrinthitis

• Medications:
  • Short course of steroids
  • Vestibular rehabilitation is recommended 1

3. Ménière's Disease

• Pharmacological treatment:

  • Diuretics to reduce endolymph volume 1
  • Betahistine (shows 56% reduction in vertigo compared to placebo) 1

• Lifestyle modifications:

  • Abundant water intake
  • Sleeping in a dark room
  • Stress management techniques 1
  • Documentation of symptoms (vertigo, tinnitus, hearing loss) and quality of life after treatment 2

4. Acute Spontaneous Vertigo

• Medications:
  • Meclizine: 25 mg to 100 mg daily in divided doses 3
  • Vestibular suppressants for symptomatic relief

Symptomatic Management

• For neurovegetative symptoms:

  • Antiemetics: Prochlorperazine, metoclopramide, ondansetron 1
  • Prokinetic antiemetics like domperidone and metoclopramide can help manage nausea and vomiting 1

• For anxiety/agitation:

  • Benzodiazepines may be used short-term, but caution is advised due to sedation 1

• For vestibular migraine:

  • Beta-blockers, anticonvulsants, or antidepressants for prophylaxis 1

Vestibular Rehabilitation

• Can be self-administered or clinician-guided
• Particularly beneficial for elderly patients
• May decrease recurrence rates 1
• Effective for vestibular hypofunction 4

Important Precautions

• Medication side effects:

  • Meclizine may cause drowsiness - caution when driving or operating machinery 3
  • Anticholinergic effects - use with care in patients with asthma, glaucoma, or prostate enlargement 3
  • Coadministration with other CNS depressants, including alcohol, may increase CNS depression 3

• Fall prevention:

  • Patients should be advised about increased fall risk, especially in the elderly 1
  • Home safety assessment is crucial 1

Follow-up and Monitoring

• Reassess within 1 month after initial treatment 2, 1
• Document resolution, improvement, or worsening of vertigo, tinnitus, and hearing loss 2
• Evaluate treatment failures for persistent symptoms, incorrect diagnosis, or underlying disorders 2

Special Considerations

• Elderly patients may benefit more from vestibular rehabilitation in addition to CRPs 1
• Patients with mobility issues may require assistance or modified techniques 1
• Pregnant women can use metoclopramide under supervision 1

The treatment approach should be guided by accurate diagnosis, with BPPV being the most common cause of vertigo in primary care that can often be cured immediately with proper repositioning maneuvers 5. For medication-based treatment, meclizine is FDA-approved specifically for vertigo associated with diseases affecting the vestibular system 3.