What are the treatment options for vertigo?

Treatment Options for Vertigo

The primary treatment for vertigo should be targeted to the underlying cause, with canalith repositioning procedures being the first-line treatment for BPPV (the most common cause), while vestibular suppressants like meclizine (25-100 mg daily) should be used only for short-term symptomatic relief of acute vertigo. 1, 2

Treatment Based on Vertigo Type

Benign Paroxysmal Positional Vertigo (BPPV) - 42% of cases

• First-line treatment: Physical therapy through canalith repositioning procedures
  • 80-90% success rates after 1-2 treatments 1
  • Examples include Epley, Semont, or Lempert maneuvers
• Avoid: Long-term medication use as it doesn't address the underlying cause

Vestibular Neuritis/Labyrinthitis - 41% of cases

• Acute phase treatment:
  • Short course of oral corticosteroids (prednisone or methylprednisolone) for 7-14 days with tapering dose 1
  • Vestibular suppressants for symptomatic relief only:
    • Meclizine 25-100 mg daily in divided doses 2
    • Benzodiazepines (e.g., diazepam) for severe symptoms
• Recovery phase: Vestibular rehabilitation exercises to promote compensation

Menière's Disease - 10% of cases

• Dietary modifications: Low-salt diet
• Medications:
  • Diuretics (reduce endolymph volume and vertigo attacks by 56% compared to placebo) 1
  • Betahistine (long-term high-dose treatment) 3
• For acute attacks: Vestibular suppressants

Vestibular Migraine - up to 14% of cases

• Prophylactic medications:
  • Beta-blockers
  • Anticonvulsants
  • Antidepressants
  • Calcium channel antagonists 1, 4
• Lifestyle modifications: Migraine triggers avoidance

Central Vertigo - 3% of cases

• Treatment: Directed at underlying cause (stroke, multiple sclerosis, etc.)
• Imaging: MRI head/internal auditory canal without/with contrast 1

Pharmacological Options for Symptomatic Relief

Vestibular Suppressants

• Antihistamines:

  • Meclizine (FDA-approved for vertigo): 25-100 mg daily in divided doses 2
  • Caution: May cause drowsiness; use care when driving or operating machinery 2

• Benzodiazepines:

  • For severe symptoms or anxiety-associated vertigo
  • Short-term use only to prevent delayed vestibular compensation 1

• Dopamine receptor antagonists:

  • Prochlorperazine, metoclopramide
  • Helpful for associated nausea and vomiting 1

• Antiemetics:

  • Ondansetron (5-HT3 antagonist)
  • Prokinetic antiemetics (domperidone, metoclopramide) 1

Rehabilitation and Lifestyle Modifications

• Vestibular rehabilitation:

  • Self-administered or clinician-guided therapy
  • Particularly beneficial for elderly patients
  • May decrease recurrence rates 1

• Regular physical activity:

  • Cardio-exercise for at least 30 minutes twice weekly 1

• Home safety assessment:

  • Crucial to prevent falls in patients with vertigo 1

Important Considerations and Pitfalls

1. Avoid long-term use of vestibular suppressants:

   • Can delay natural vestibular compensation 1
   • Use only for short-term symptomatic relief

2. Distinguish between peripheral and central causes:

   • HINTS examination (Head-Impulse, Nystagmus, Test of Skew) is more sensitive than early MRI for detecting stroke (100% vs 46%) 1

3. Medication interactions:

   • Meclizine may interact with other CNS depressants, including alcohol 2
   • CYP2D6 inhibitors may interact with meclizine 2

4. Special populations:

   • Pregnant women: Metoclopramide can be used under supervision 1
   • Patients with history of asthma, glaucoma, or prostate enlargement: Use anticholinergic medications with caution 2

5. Consider medication-induced vertigo:

   • Aminoglycosides, cycloserine, and certain anticonvulsants are common culprits 1
   • Particularly in patients with renal impairment or advanced age

6. When to refer:

   • Unilateral tinnitus
   • Persistent symptoms (≥6 months)
   • Associated hearing difficulties
   • Focal neurological abnormalities
   • Symptoms unresponsive to initial treatment