How is vertigo treated?

Treatment of Vertigo

The treatment of vertigo should be tailored to the specific underlying cause, with first-line interventions including canalith repositioning procedures for BPPV, vestibular rehabilitation for vestibular neuritis, and medication management for Ménière's disease. 1

Diagnosis and Classification

Before initiating treatment, it's essential to identify the cause of vertigo:

• Benign Paroxysmal Positional Vertigo (BPPV) - 42% of vertigo cases in non-specialty settings
• Vestibular Neuritis - 41% of cases
• Ménière's Disease - 10% of cases
• Migraine-associated Vertigo - up to 14% of cases
• Vascular Causes - 3% of cases 1

Key diagnostic tests:

• Dix-Hallpike test - gold standard for diagnosing BPPV
• HINTS examination (Head-Impulse, Nystagmus, Test of Skew) - more sensitive than early MRI for detecting stroke in patients with vertigo 1

Treatment Approaches by Condition

1. Benign Paroxysmal Positional Vertigo (BPPV)

• First-line treatment: Physical therapy through canalith repositioning procedures (80-90% success rates after 1-2 treatments) 1
• Options include:
  • Semont maneuver
  • Epley maneuver
  • Lempert maneuver (for horizontal canal BPPV)

2. Vestibular Neuritis/Labyrinthitis

• Acute management:

  • Short course of oral corticosteroids (prednisone or methylprednisolone) for 7-14 days with tapering dose 1
  • Vestibular suppressants for short-term symptomatic relief only
  • Patient positioning: lie on healthy side with head and trunk raised 20 degrees 2

• Rehabilitation:

  • Vestibular rehabilitation exercises (self-administered or clinician-guided) 1
  • Vestibular electrical stimulation to reduce antigravitary failure 2

3. Ménière's Disease

• Medication management:

  • Diuretics (reduce endolymph volume and vertigo attacks by 56% compared to placebo) 1
  • Low-salt diet combined with diuretics 3

• For refractory cases:

  • Intratympanic steroid injections 1
  • Transtympanic gentamicin for cases with non-usable hearing 1

• Monitoring: Document resolution, improvement, or worsening of vertigo, tinnitus, and hearing loss and any change in quality of life after treatment 4

4. Vestibular Migraine

• Prophylactic medications:
  • Beta-blockers
  • Anticonvulsants
  • Antidepressants 1
  • Gabapentin (300 mg 2-3 times daily) can help stabilize the visual field 2

Symptomatic Management for Acute Vertigo

• FDA-approved medication: Meclizine hydrochloride 25 mg to 100 mg daily in divided doses for vertigo associated with diseases affecting the vestibular system 5

• Other medications for symptom control:

  • Antiemetics: Prochlorperazine, metoclopramide, ondansetron 1
  • Benzodiazepines: Diazepam (10 mg once or twice daily) to decrease internuclear inhibition 2
  • Prokinetic antiemetics: Domperidone, metoclopramide 1

Important Considerations and Precautions

• Vestibular suppressants should be used short-term only as long-term use can delay vestibular compensation 1

• Medication precautions:

  • Meclizine may cause drowsiness; use caution when driving or operating machinery 5
  • Potential anticholinergic effects with meclizine; prescribe with care to patients with asthma, glaucoma, or prostate enlargement 5
  • Coadministration of meclizine with other CNS depressants, including alcohol, may increase CNS depression 5

• Fall prevention:

  • Home safety assessment is crucial for patients with vertigo, especially the elderly 1
  • Regular physical activity (cardio-exercise for at least 30 minutes twice weekly) is recommended 1

Follow-up and Monitoring

• Document resolution, improvement, or worsening of vertigo symptoms after treatment 4
• Assess impact on quality of life using consistent evaluation measures 4
• Frequency of follow-up should be based on severity and progression of disease 4
• Counsel patients about recurrence risk (10-18% at 1 year and up to 36% long-term for BPPV) 1

Treatment Algorithm

1. Identify cause through history, physical examination, and appropriate tests
2. For BPPV: Implement canalith repositioning procedures
3. For vestibular neuritis: Short-term vestibular suppressants + corticosteroids + vestibular rehabilitation
4. For Ménière's disease: Low-salt diet + diuretics; escalate to intratympanic therapies if refractory
5. For vestibular migraine: Prophylactic medications + trigger avoidance
6. For all types: Provide symptomatic relief during acute attacks and implement fall prevention strategies