What are the treatment options for vertigo?

Treatment Options for Vertigo

The primary evidence-based treatments for vertigo depend on the underlying cause, with canalith repositioning procedures (Epley or Semont maneuver) being the first-line treatment for benign paroxysmal positional vertigo (BPPV), while medications like meclizine (25-100 mg daily) are indicated for vertigo associated with vestibular system diseases. 1, 2

Diagnostic Classification to Guide Treatment

Before initiating treatment, it's essential to classify vertigo based on its cause:

1. Peripheral Causes (most common in primary care):

   • Benign Paroxysmal Positional Vertigo (BPPV) - 42% of cases
   • Vestibular Neuritis - 41% of cases
   • Ménière's Disease - 10% of cases

2. Central Causes:

   • Vestibular Migraine - up to 14% of cases
   • Vascular causes - 3% of cases

Treatment Approaches by Specific Condition

1. Benign Paroxysmal Positional Vertigo (BPPV)

• First-line treatment: Canalith repositioning procedures (CRPs)
  • Epley or Semont maneuver (80-90% success rate after 1-2 treatments) 1
  • These procedures should be performed before considering medication
• Adjunct therapy: Vestibular rehabilitation exercises (particularly beneficial for elderly patients)
• Important: The American Academy of Otolaryngology-Head and Neck Surgery recommends against routinely using vestibular suppressant medications for BPPV 1

2. Vestibular Neuritis/Labyrinthitis

• Acute phase treatment:
  • Short course of oral corticosteroids (prednisone or methylprednisolone) for 7-14 days with tapering dose 1
  • Vestibular suppressants for symptom control only during acute phase
• Recovery phase: Vestibular rehabilitation exercises to promote compensation

3. Ménière's Disease

• First-line therapy: Low-salt diet combined with diuretics (reduces vertigo attacks by 56% compared to placebo) 1
• For acute attacks: Vestibular suppressants and antiemetics
• Refractory cases: Transtympanic gentamicin for patients with non-usable hearing 1

4. Vestibular Migraine

• Prophylactic treatment: Beta-blockers, anticonvulsants, or antidepressants 1
• Acute attacks: Similar management to other migraines

Pharmacological Options

1. Vestibular Suppressants

• Meclizine (FDA-approved for vertigo):
  • Dosage: 25-100 mg daily in divided doses 2
  • Indicated specifically for vertigo associated with vestibular system diseases
  • Warning: May cause drowsiness; use caution when driving or operating machinery 2
  • Contraindicated in patients with hypersensitivity to meclizine 2

2. Other Medication Options

• Antiemetics:

  • Prokinetic antiemetics (domperidone, metoclopramide) - useful for managing nausea without significantly interfering with vestibular compensation 1
  • Dopamine receptor antagonists (prochlorperazine, metoclopramide) 1
  • 5-HT3 antagonists (ondansetron) for severe nausea 1

• Benzodiazepines (e.g., lorazepam):

  • For acute symptom control
  • Caution: Long-term use can delay vestibular compensation 1

Important Clinical Considerations

• Avoid prolonged use of vestibular suppressants as they can delay central compensation and recovery 1
• Reassess patients within 1 month after initial treatment to confirm symptom resolution 1
• Avoid unnecessary imaging unless diagnosis is uncertain or additional symptoms warrant testing 1
• Patient education is crucial:
  • Explain mechanism of vertigo
  • Discuss fall prevention strategies
  • Review warning signs requiring further evaluation
  • Provide reassurance about generally favorable prognosis
  • Explain possibility of recurrence (10-18% at 1 year, up to 36% long-term for BPPV) 1

Special Considerations

• Elderly patients are at higher risk for falls; home safety assessment is crucial 1
• Patients with asthma, glaucoma, or prostate enlargement should use meclizine with caution due to potential anticholinergic effects 2
• Drug interactions: Meclizine may increase CNS depression when used with other CNS depressants, including alcohol 2

Remember that most vertigo cases in primary care are benign peripheral causes that can be effectively managed with appropriate treatment, and many will resolve with time and proper management.