Treatment Options for Vertigo
The primary treatment for vertigo depends on the underlying cause, with canalith repositioning procedures (Epley or Semont maneuver) being the first-line treatment for BPPV with 80-90% success rates, while vestibular suppressant medications such as meclizine (25-100 mg daily) are indicated for vertigo associated with vestibular system diseases. 1, 2
Diagnosis-Based Treatment Approach
Benign Paroxysmal Positional Vertigo (BPPV) - 42% of cases
- First-line treatment: Canalith repositioning procedures (CRPs)
- Epley or Semont maneuver (80-90% success after 1-2 treatments) 1
- Should be performed before considering medication
- Alternative options:
- Vestibular rehabilitation exercises (self-administered or clinician-guided)
- Particularly beneficial for elderly patients
- May decrease recurrence rates 1
- Not recommended: Routine use of vestibular suppressant medications 1
- Patient education: Counsel about high recurrence risk (10-18% at 1 year, up to 36% long-term) 1
Vestibular Neuritis/Labyrinthitis - 41% of cases
- Acute phase management:
- Recovery phase:
- Vestibular rehabilitation exercises to promote central compensation
- Discontinue vestibular suppressants as soon as possible (long-term use delays compensation) 1
Ménière's Disease - 10% of cases
- First-line treatment:
- Low-salt diet combined with diuretics (reduces endolymph volume and vertigo attacks by 56%) 1
- Vestibular suppressants during acute attacks
- Refractory cases:
- Transtympanic gentamicin for cases with non-usable hearing 1
Vestibular Migraine - up to 14% of cases
- Acute treatment:
- Antiemetics and vestibular suppressants for symptom control
- Prophylaxis:
- Beta-blockers, anticonvulsants, or antidepressants 1
- Lifestyle modifications (trigger avoidance)
Central Causes of Vertigo - 3% of cases
- Requires neurological evaluation and targeted treatment of underlying cause
- MRI head/internal auditory canal without/with contrast is recommended 1
Pharmacological Options
Vestibular Suppressants
Meclizine (FDA-approved for vertigo)
- Dosage: 25 mg to 100 mg daily in divided doses 2
- Warning: May cause drowsiness; use caution when driving or operating machinery 2
- Contraindications: Hypersensitivity to meclizine; use with caution in patients with asthma, glaucoma, or prostate enlargement 2
- Common adverse effects: Drowsiness, dry mouth, headache, fatigue, vomiting, rarely blurred vision 2
Other vestibular suppressants:
- Antihistamines
- Benzodiazepines (e.g., lorazepam)
- Dopamine receptor antagonists (prochlorperazine, metoclopramide) 1
Antiemetics
- Prokinetic antiemetics: Domperidone, metoclopramide
- 5-HT3 antagonists: Ondansetron (can be used in combination therapy) 1
Important Clinical Considerations
Cautions and Pitfalls
- Avoid long-term use of vestibular suppressants - delays central compensation and prolongs recovery 1
- Drug interactions: Meclizine with other CNS depressants (including alcohol) may increase CNS depression 2
- CYP2D6 inhibitors may interact with meclizine 2
- Avoid unnecessary imaging unless diagnosis is uncertain or additional symptoms warrant testing 1
Follow-up and Monitoring
- Reassess patients within 1 month after initial treatment to confirm symptom resolution 1
- Implement home safety assessment to prevent falls 1
- Educate patients about recognizing recurrence symptoms for prompt treatment 1
Special Populations
- Elderly patients: May benefit particularly from vestibular rehabilitation exercises 1
- Patients with hearing symptoms: Should undergo audiometry and tympanometry as part of diagnostic evaluation 1
Diagnostic Approach to Guide Treatment
- Use the HINTS examination (Head-Impulse, Nystagmus, Test of Skew) to distinguish peripheral from central causes (100% sensitivity vs 46% for early MRI) 1
- For BPPV: Dix-Hallpike test to confirm diagnosis before performing repositioning maneuvers 1, 3
- For Ménière's disease: Audiometry to document low-to-midfrequency sensorineural hearing loss 1