What are the treatment options for vertigo?

Treatment Options for Vertigo

The primary treatment for vertigo should be targeted to the specific underlying cause, with canalith repositioning procedures being the most effective first-line treatment for benign paroxysmal positional vertigo (BPPV), which has 80-90% success rates after 1-2 treatments. 1

Diagnosis-Based Treatment Approach

1. Benign Paroxysmal Positional Vertigo (BPPV)

• First-line treatment: Canalith repositioning procedures (Epley, Semont, or Lempert maneuvers)
  • Physical therapy-based approach addresses the underlying cause
  • 80-90% success rate after 1-2 treatments 1
• Self-administered or clinician-guided vestibular rehabilitation exercises
• Avoid long-term vestibular suppressant medications as they delay compensation 1

2. Acute Vestibular Neuronitis/Labyrinthitis

• Short-term vestibular suppressants for symptomatic relief:
  • Meclizine 25-100 mg daily in divided doses 2
  • Benzodiazepines (e.g., diazepam, lorazepam)
  • Antihistamines
• Short course of oral corticosteroids (7-14 days with tapering) 1
• Vestibular rehabilitation exercises after acute phase

3. Ménière's Disease

• Lifestyle modifications:
  • Low-salt diet
  • Diuretics (reduce endolymph volume and vertigo attacks by 56% compared to placebo) 1
• For acute attacks:
  • Vestibular suppressants
  • Antiemetics for nausea/vomiting
• For refractory cases:
  • Intratympanic steroid injections 1
  • Transtympanic gentamicin (for non-usable hearing) 3

4. Vestibular Migraine

• Prophylactic medications:
  • Beta-blockers
  • Tricyclic antidepressants
  • Calcium channel blockers 1
• Dietary modifications
• Trigger avoidance

Pharmacological Options

Vestibular Suppressants

• Meclizine: 25-100 mg daily in divided doses 2
  • FDA-approved specifically for "treatment of vertigo associated with diseases affecting the vestibular system in adults"
  • Important: Use only for short-term relief as long-term use delays vestibular compensation 1

Antiemetics

• Prokinetic antiemetics: Domperidone, metoclopramide
  • Useful adjuncts for managing nausea without significantly interfering with vestibular compensation 1
• 5-HT3 antagonists: Ondansetron
• Dopamine receptor antagonists: Prochlorperazine, metoclopramide

Other Medications

• Corticosteroids: For inflammatory causes
  • Oral prednisone/methylprednisolone for 7-14 days with tapering
  • Intratympanic injections for refractory cases 1
• Diuretics: For Ménière's disease

Non-Pharmacological Approaches

Vestibular Rehabilitation

• Highly effective for many types of vertigo, particularly BPPV and unilateral vestibular hypofunction
• Can be self-administered or clinician-guided
• May decrease recurrence rates, particularly beneficial for elderly patients 1

Lifestyle Modifications

• Regular physical activity (cardio-exercise for at least 30 minutes twice weekly) 1
• Home safety assessment to prevent falls
• Patient education about fall risk and symptom recognition

Treatment Pitfalls and Caveats

1. Avoid prolonged use of vestibular suppressants

   • Long-term use delays natural vestibular compensation 1
   • Use only for short-term symptomatic relief

2. Consider medication side effects

   • Vestibular suppressants may cause drowsiness and impair driving ability 2
   • Use caution in patients with glaucoma, asthma, or prostate enlargement due to anticholinergic effects 2

3. Rule out central causes

   • Use HINTS examination (Head-Impulse, Nystagmus, Test of Skew) to distinguish peripheral from central causes
   • Central causes may require different management approaches 1

4. Recognize when to refer

   • Persistent symptoms despite appropriate treatment
   • Unilateral tinnitus or asymmetric hearing loss
   • Focal neurological abnormalities

By following this structured approach based on the specific diagnosis, most vertigo cases can be effectively managed in the primary care setting without extensive diagnostic testing.