Treatment for Vertigo
The primary treatment for vertigo should be based on the underlying cause, with canalith repositioning procedures (such as the Epley maneuver) being the first-line treatment for BPPV (which accounts for 42% of cases), achieving 80-90% success rates after 1-2 treatments. 1
Diagnosis and Assessment
Before initiating treatment, it's crucial to determine whether the vertigo is peripheral or central in origin:
- Peripheral causes (inner ear): BPPV (42%), vestibular neuritis (41%), Menière's disease (10%)
- Central causes (brain): Stroke, migraine-associated vertigo (14%), multiple sclerosis
Key diagnostic tests:
- Dix-Hallpike test: Gold standard for diagnosing BPPV 1
- HINTS examination: More sensitive than early MRI for detecting stroke (100% vs 46%) 1
- Audiologic testing: For unilateral tinnitus, persistent symptoms, or hearing difficulties 1
Treatment by Cause
1. Benign Paroxysmal Positional Vertigo (BPPV)
- First-line treatment: Canalith repositioning procedures (Epley maneuver) 1, 2
- 80-90% success rate after 1-2 treatments
- Addresses the underlying cause rather than just symptoms
- Avoid: Vestibular suppressant medications like meclizine are not recommended by guidelines for BPPV 2
2. Vestibular Neuritis
- Acute management: Short-term use of vestibular suppressants only 1
- Corticosteroids: Short course (7-14 days) of oral prednisone or methylprednisolone with tapering dose 1
- Vestibular rehabilitation: To promote compensation 1
3. Menière's Disease
- Dietary modifications: Salt restriction 3
- Diuretics: To reduce endolymph volume (56% reduction in vertigo attacks compared to placebo) 1
- Acute attacks: Vestibular suppressants 1, 3
- Refractory cases: Transtympanic gentamicin for patients with non-usable hearing 1
4. Migraine-Associated Vertigo
- Prophylactic medications:
Pharmacological Management
Vestibular Suppressants (for acute symptom relief only)
- Meclizine (antihistamine): 25-100 mg daily in divided doses 4
- Benzodiazepines: Useful for acute vertigo and anxiety-related vertigo 3
- Dopamine receptor antagonists: Prochlorperazine, metoclopramide 1
- Metoclopramide can be used under supervision in pregnant women 1
Important Cautions
- Short-term use only: Long-term use of vestibular suppressants can delay vestibular compensation 1
- Driving restrictions: May cause drowsiness; use caution when driving or operating machinery 4
- Drug interactions: Avoid co-administration with other CNS depressants including alcohol 4
- CYP2D6 inhibitors: Potential for drug-drug interactions with meclizine 4
Vestibular Rehabilitation
- Self-administered or clinician-guided therapy: Particularly beneficial for elderly patients 1
- Regular physical activity: Cardio-exercise for at least 30 minutes twice weekly 1
- Home safety assessment: Crucial to prevent falls 1
Common Pitfalls to Avoid
- Overreliance on medications: Vestibular suppressants treat symptoms but not the underlying cause, especially in BPPV 1, 2
- Unnecessary imaging: Brain imaging is not routinely recommended for typical peripheral vertigo 2
- Missing central causes: Always evaluate for neurological signs that might indicate stroke or other central causes 1
- Prolonged medication use: Extended use of vestibular suppressants can impair central compensation 1
- Failure to identify BPPV: As the most common cause, BPPV should be ruled out first with the Dix-Hallpike test 1, 2
Remember that the appropriate treatment approach depends on correctly identifying the underlying cause of vertigo, with physical maneuvers being superior to medications for BPPV, while medications play a more significant role in other conditions like Menière's disease and vestibular migraine.