How is vertigo treated?

Treatment of Vertigo

The primary treatment for vertigo should be targeted to the underlying cause, with canalith repositioning procedures being the first-line treatment for BPPV (80-90% success rate), vestibular suppressants for acute symptomatic relief, and vestibular rehabilitation for long-term management. 1

Diagnosis and Classification

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

1. Common causes of vertigo:

   • Benign Paroxysmal Positional Vertigo (BPPV): 42% of cases
   • Vestibular neuritis: 41% of cases
   • Menière's disease: 10% of cases
   • Migraine-associated vertigo: up to 14% of cases
   • Vascular causes: 3% of cases 1

2. Diagnostic approach:

   • 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 (100% vs 46%) 1
   • Audiologic testing: For patients with unilateral tinnitus, persistent symptoms, or hearing difficulties

Treatment Algorithm

1. BPPV Treatment

• First-line: Canalith repositioning procedures (Epley, Semont, or Lempert maneuvers) with 80-90% success rates after 1-2 treatments 1, 2
• Follow-up: Patient education about high recurrence risk (10-18% at 1 year, up to 36% long-term)

2. Vestibular Neuritis/Labyrinthitis Treatment

• 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
• Long-term management: Vestibular rehabilitation exercises

3. Menière's Disease Treatment

• First-line: Low-salt diet and diuretics (reduce endolymph volume and vertigo attacks by 56% compared to placebo) 1, 3
• Second-line: Intratympanic steroid injections for cases not responsive to oral treatment 1
• Refractory cases: Transtympanic gentamicin for patients with non-usable hearing 1

4. Vestibular Migraine Treatment

• Prophylaxis: Beta-blockers, anticonvulsants, or antidepressants 1
• Acute treatment: Similar to migraine headache management

Pharmacological Management

1. Vestibular suppressants (for short-term use only):

   • Meclizine: 25 mg to 100 mg daily in divided doses 4
   • Benzodiazepines: Diazepam 10 mg once or twice daily 2
   • Antiemetics:
     • Metoclopramide 10 mg once or twice daily
     • Prochlorperazine
     • Ondansetron 1

2. Important caution: Vestibular suppressants should be used for short-term symptomatic relief only, as long-term use can delay vestibular compensation 1

3. Side effects to monitor:

   • Drowsiness: Use caution when driving or operating machinery
   • Anticholinergic effects: Use with care in patients with asthma, glaucoma, or prostate enlargement 4

Non-Pharmacological Approaches

1. Vestibular rehabilitation:

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

2. Physical activity:

   • Regular cardio-exercise for at least 30 minutes twice weekly
   • Vestibular electrical stimulation: Superficial paravertebral electrical stimulation of neck muscles 2

3. Fall prevention:

   • Home safety assessment
   • Activity restrictions until vertigo resolves, especially for elderly patients 1

Monitoring and Follow-up

Clinicians should document resolution, improvement, or worsening of vertigo, tinnitus, and hearing loss, as well as any change in quality of life after treatment 5. This follow-up allows for:

• Evaluation of treatment effectiveness
• Identification of patients who need increased or decreased intensity of therapy
• Reduction of ineffective therapy use
• Early detection of disease progression

Special Considerations

1. Pregnancy: Metoclopramide can be used under supervision 1

2. Medication-induced vertigo: Several medication classes can cause vertigo as an adverse effect, particularly in patients with renal impairment or advanced age 1

3. Central causes: Require urgent evaluation and treatment if suspected based on neurological signs or HINTS examination 1

4. Surgical options: Reserved for patients who have not benefited from less definitive therapy and have non-usable hearing 6

The treatment of vertigo requires a targeted approach based on accurate diagnosis, with the goal of controlling symptoms, improving quality of life, and addressing the underlying cause when possible.