What are the recommended management options for vertigo?

Management of Vertigo

The primary management of vertigo should be based on the underlying cause, with canalith repositioning procedures (CRPs) as first-line treatment for benign paroxysmal positional vertigo (BPPV), vestibular rehabilitation for vestibular hypofunction, and targeted pharmacotherapy for specific conditions like Ménière's disease and vestibular neuritis. 1

Diagnostic Approach

Before initiating treatment, proper diagnosis is essential:

1. Classify by timing and triggers:

   • Spontaneous episodic vestibular syndrome
   • Triggered episodic vestibular syndrome
   • Acute vestibular syndrome 2

2. Key diagnostic tests:

   • HINTS examination (Head-Impulse, Nystagmus, Test of Skew) - more sensitive than early MRI for detecting stroke (100% vs 46%) 1
   • Dix-Hallpike maneuver for BPPV diagnosis 1
   • Audiometry - essential for documenting hearing loss in Ménière's disease 1

Treatment by Specific Conditions

1. Benign Paroxysmal Positional Vertigo (BPPV)

• First-line treatment: Canalith repositioning procedures (Epley or Semont maneuver) - 80-90% success rate after 1-2 treatments 1
• Adjunctive therapy: Vestibular rehabilitation exercises (self-administered or clinician-guided) 1
• Important: Avoid routine use of vestibular suppressant medications 1

2. Vestibular Neuritis/Labyrinthitis

• Acute phase: Vestibular suppressants for symptom control 1
• Short-term: Oral corticosteroids (prednisone or methylprednisolone) for 7-14 days with tapering dose 1
• Recovery phase: Vestibular rehabilitation exercises 1, 2

3. Ménière's Disease

• First-line: Low-salt diet and diuretics (reduce endolymph volume and vertigo attacks by 56% compared to placebo) 1, 3
• Acute attacks: Vestibular suppressants and antiemetics 1
• Refractory cases: Transtympanic gentamicin for patients with non-usable hearing 1, 2

4. Vestibular Migraine

• Prophylaxis: Beta-blockers, anticonvulsants, or antidepressants 1
• Dietary modifications: Avoid migraine triggers 3

Pharmacological Management

1. Vestibular Suppressants

• Meclizine: 25-100 mg daily in divided doses for vertigo associated with vestibular system diseases 4
  • Caution: Causes drowsiness; avoid alcohol and operating machinery 4
  • Contraindications: Use with caution in patients with asthma, glaucoma, or prostate enlargement 4

2. Other Medications

• Antiemetics: Prokinetic agents (domperidone, metoclopramide) for nausea without significantly interfering with vestibular compensation 1
• Benzodiazepines: For acute vertigo attacks, but avoid long-term use as they delay vestibular compensation 1
• Corticosteroids: Short course for inflammatory conditions 1

Vestibular Rehabilitation

• Indications: Effective for vestibular hypofunction and BPPV 1, 2
• Benefits: Improves balance, reduces fall risk, and accelerates central compensation 1
• Delivery: Can be self-administered or directed by a physical therapist 2

Patient Education and Follow-up

• Fall prevention: Home safety assessment is crucial 1
• Recurrence counseling: BPPV has a high recurrence risk (10-18% at 1 year, up to 36% long-term) 1
• Follow-up: Reassess within 1 month after initial treatment 1
• Avoid unnecessary testing: Routine neuroimaging and vestibular testing are not recommended unless diagnosis is uncertain 1, 2

Common Pitfalls to Avoid

1. Overuse of vestibular suppressants: Can delay central compensation and recovery 1
2. Missing central causes: Always perform HINTS examination to distinguish peripheral from central causes 1
3. Inadequate follow-up: Vertigo conditions often recur and require reassessment 1
4. Treating symptoms without diagnosis: Different vertigo causes require specific treatments 1, 2

Remember that while pharmacotherapy can provide symptom relief, it is often not curative. Definitive treatments like canalith repositioning for BPPV and vestibular rehabilitation for vestibular hypofunction should be prioritized when indicated 2.