What is the best medication for treating peripheral vertigo, such as Benign Paroxysmal Peripheral Vertigo (BPPV)?

Treatment of Peripheral Vertigo (BPPV)

Canalith repositioning procedures (CRPs), not medications, are the first-line treatment for benign paroxysmal positional vertigo (BPPV). 1, 2

First-Line Treatment Approach

• The Epley maneuver (canalith repositioning procedure) is the treatment of choice for posterior canal BPPV, with success rates of approximately 80% with just 1-3 treatments 1, 2
• For horizontal canal BPPV, the Barbecue Roll Maneuver (Lempert maneuver) or Gufoni maneuver are the recommended first-line treatments 1, 3
• The Liberatory Maneuver (Semont maneuver) is an effective alternative for posterior canal BPPV with comparable efficacy to the Epley maneuver 1, 4
• Patients treated with CRP have 6.5 times greater chance of symptom improvement compared to controls 1
• A single CRP is more than 10 times more effective than a week of Brandt-Daroff exercises 1, 4

Medication Use in BPPV

• Vestibular suppressant medications (antihistamines, benzodiazepines) should NOT be routinely used for treating BPPV 2
• There is no evidence in the literature suggesting that vestibular suppressant medications are effective as a definitive, primary treatment for BPPV 2
• While meclizine is FDA-approved for "vertigo associated with diseases affecting the vestibular system," it is not recommended as primary treatment for BPPV 5, 2
• Vestibular suppressant medications can cause significant adverse effects including:
  • Drowsiness and cognitive deficits 2
  • Increased risk of falls, especially in elderly patients 2
  • Interference with central compensation in peripheral vestibular conditions 2
  • Decreased diagnostic sensitivity during Dix-Hallpike maneuvers 2

Limited Role for Medications

• Vestibular suppressant medications may be considered only for short-term management of severe autonomic symptoms (nausea, vomiting) in severely symptomatic patients 2, 6
• These medications should be used temporarily until more definitive treatment (CRP) can be provided 6
• The addition of a benzodiazepine to CRP may help decrease emotional and functional scores on the Dizziness Handicap Inventory but does not affect physical symptoms 2

Treatment Failures

• If symptoms persist after initial treatment, patients should be reevaluated for:
  • Persistent BPPV that may respond to additional repositioning maneuvers 2
  • Involvement of other semicircular canals (canal conversion occurs in about 6-7% of cases) 1, 2
  • Coexisting vestibular conditions 2
  • Possible CNS disorders (found in approximately 3% of treatment failures) 2
• Repeat CRPs can achieve success rates of 90-98% for persistent BPPV 2
• Surgical options (canal plugging) should only be considered for intractable cases after multiple failed CRPs 7

Self-Treatment Options

• Self-administered CRP can be taught to motivated patients and appears more effective (64% improvement) than self-treatment with Brandt-Daroff exercises (23% improvement) 1
• Patients with physical limitations or severe symptoms should be referred to healthcare professionals experienced in performing repositioning maneuvers 1

Follow-up

• Patients should be reassessed within 1 month after initial treatment to confirm symptom resolution 6
• Mild residual symptoms may persist for a few days to weeks after successful treatment 1